Order PrismRA Test Kits

Fill out the form below with the required information to order your PrismRA kit(s).

If you have any questions, please contact Provider Relations at (855) 724-7437. Thank you for placing your order!

Name*
First Last
Physicians Name (if different than above)
First Last
NPI Number (if applicable)
Address*
P.O boxes will not be accepted

Street Address Address Line 2 City State ZIP Code
Attention To (if different from above)
First Last
Phone*
(###) ###-####
Email*
Quantity*
Special Request/Instructions
Requested Receipt Date*
MM slash DD slash YYYY
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