1. Fill out the top section with your name and select the test(s) requested.
2. Fill out the bottom section with your Clinician's Name, address, and contact information.
3. Print the form and bring it to your clinician as a request for testing.
4. The form provides your clinician information to contact Metametrix for testing details, to establish an account, and to order your requested testing.

If your clinician is unable or unwilling to arrange the selected tests/profiles for you, please refer to our Patient Support Program.