NY/NJ form

Gut Microbiome Test Requisition Form

IMPORTANT: This form must be completed and signed before you return your sample. Any sample received without a requisition form will not be processed.

Use this form only if your sample was collected in New York or New Jersey.

Patient Information

Sample Information

Copy the barcode on your sample tube exactly as printed.

Letters, numbers and dashes only.

Patient Consent and Signature

Date: 10/19/2026 (set when you submit)

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