GI-Map Online Test Order (For Testing Only)

GI-Map Test – Practitioner Ordering

GI-MAP TEST REQUEST FORM
Designs for Health
Registered Practitioners

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Designs for Health Practitioner?
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GI-Map Test – Complete Program procedure

Complete the Test Request Form on this page
Full Payment is required. The GI-MAP Test Program is $445 and includes:

- GI-MAP Test Kit
- Laboratory Analysis and Report
- Optional Report interpretation – phone consultation with DFH advisor
Payment instructions are provided when you submit the Test Request Form. Payment options are:
- Your patient can pay for the GI-MAP Test Program directly (payment link sent via email after you submit the patient’s Test Request Form)
- You can pay on behalf of your patient through our web store
- Pay on your pre-approved 30-Day practitioner account (this option can also be used if you have authorised DFH-AU to store your credit card details on file)
Prepare your patient and provide instructions for sample collection
(Also included in the GI-MAP Test Kit)
The patient sends the sample to Designs for Health in a postage bag provided
Designs for Health Australia sends the sample to Diagnostic Solutions Laboratory for analysis
Once the test results are ready, Diagnostic Solutions Laboratory will send the GI-MAP Analysis Report to Designs for Health Australia.
You will be advised as soon as the Report is available
Consultations are available by appointment for an Analysis Report Interpretation

Please refer to the GI-MAP Downloads and Resources page…

GI-MAP DOWNLOADS & RESOURCES

"*" indicates required fields

PAYMENT OPTIONS: GI-MAP Test - Kit, Lab Analysis & Report*

Full payment is due to Designs for Health AU prior to sending the GI-MAP Kit to the patient. A secure payment link or procedure will be provided.

Practitioner Account (you must have a 30-Day approved account or must have your credit card details securely saved to file at Designs for Health)

Online Payment by PRACTITIONER – DFH webstore*

Payment by PATIENT**

Patient Name*

First Last

Patient Gender*

Female

Male

Patient Email*

Patient Phone*

Patient Address to deliver Test Kit*

As you have selected to pay with your pre-approved 30-Day account, we need to know your patient's address to send the Test Kit to.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Date of Birth*

Test Order Includes:
✔︎ GI-Map Test Plus Zonulin

Practitioner Name*

First Last

Clinic Name

Practitioner Email*

Practitioner Phone*

Test Request Date*

As you have selected to pay online in the DFH Web Store be sure to include the patient's address to send the Test Kit to – in the SHIPPING Address section during Checkout.

AUTHORITY TO LEAVE WITHOUT SIGNATURE*

Select an option for the courier driver to leave the parcel - OR - leave a card with further instructions

I authorise driver to leave parcel without signature

Do NOT leave the parcel if no answer

PATIENT TO COMPLETE: Sample Collection Date
Sample collected on: _____ / _____ / ________

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GI-Map Test

Practitioner Ordering

GI-Map Test Procedure

Complete the Test Request form on this page
Order the GI-Map Test Kit to be delivered
Prepare your patient and provide instructions for sample collection
(These are also included in the Test Kit)
The patient sends the sample to Designs for Health in the packaging provided
Designs for Health Australia sends the sample to Diagnostic Solutions Laboratory for analysis
The Gi-Map Analysis Report is delivered to DFH Australia, and the practitioner is advised of the payment procedure
Appointments are available for support with the report interpretation

Please refer to the GI-Map Practitioner Guide…

GI-MAP PRACTITIONER GUIDE