GI-Map + Stool OMX Online Test Order

GI-MAP + Stool OMX Test – Practitioner Ordering

GI-MAP TEST REQUEST FORM
Designs for Health
Registered Practitioners

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GI-MAP + Stool OMX Test

Complete Program Procedure

Complete the Test Request Form on this page.

Full payment is required. The GI-MAP + Stool OMX Test Program is
$475 and includes:

GI-MAP + Stool OMX Test Kit
Laboratory Analysis and Report
Optional Report Interpretation – phone consultation with a DFH advisor

Payment instructions are provided when you submit the Test Request Form. Payment options are:

Patient payment – Your patient can pay for the GI-MAP + Stool OMX Test Program directly (payment link sent via email after you submit the patient’s Test Request Form).
Practitioner payment – You can pay on behalf of your patient through our web store.
Pre-approved account – 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).

"*" indicates required fields

PAYMENT OPTIONS: GI-MAP + Stool OMX Test – Kit, Lab Analysis & Report*

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

Payment by PRACTITIONER*

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
✔︎ + Stool OMX

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: _____ / _____ / ________

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