Patient Requisition Form

/Patient Requisition Form
Patient Requisition Form2018-12-19T15:15:07+00:00

INSTRUCTIONS

  1. Click here to download our patient requisition form
  2. Print the form and complete the patient related fields
  3. Bring the form to your health care provider

IMPORTANT NOTE:

Iron Horse Diagnostics does not currently accept insurance reimbursement.  Until we begin billing insurance companies we are offering the tests at an affordable rate for patients.

Please contact us for pricing – (602) 810-0812

Your doctor will select the best test for you.  If your doctor orders the test for you, please include your credit card information in the space provided on the requisition form.  You will not be charged until Iron Horse has received your sample.  If you are not financially able to pay for the test, please contact us.