Fundamenta Wellness Patient Information

Comments

This field is for validation purposes and should be left unchanged.

Thank you for your order with Fundamenta Wellness.

Please use this form to securely send DHA Laboratory the details of the person who will be completing the testing. Your testing cannot be processed until this is received.

Your order number has been filled in automatically from the link you followed, so there is nothing to look up. Complete one submission per patient — if your order covers more than one person, submit the form once for each.

Order Details

These match your patient details to your Fundamenta Wellness order.

Order Number(Required)

Filled in automatically from your order link. If it is empty, enter the Order no. from your order confirmation.

Email Associated with Order(Required)

The email address the order was placed under.

Patient Information

The person who will be completing the testing.

Patient Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Required by the laboratory for reference ranges.

Patient Email(Required)

Where instructions and results are sent. Use the responsible party's email for a minor.

Patient Primary Phone(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Used for the collection kit and on the laboratory requisition.

Responsible Party

Only needed if the patient is a minor or is not responsible for the order.

Complete this section if the patient is a minor, or if someone other than the patient is responsible for the order.

Name of Responsible Party

Relationship to Patient

e.g. Mother, Father, Legal Guardian, Spouse.

Preferred Method of Contact

Enter a telephone number or email address.

Anything Else

Notes for DHA Laboratory

Optional. Anything the laboratory should know about this patient or order.

Have Questions? Contact us and we can help!

call email