Clinical Ordering Portal

Digital Patient Requisition & Referral Form

Licensed healthcare providers can submit patient orders directly for CLIA/CAP laboratory genomic screening covered under Medicare Part B.

For Healthcare Providers: Enter your patient's details below. Our clinical intake team will verify insurance eligibility and coordinate kit dispatch within 24 hours of submission.

Submit Patient Order

Enter patient information below. All fields marked * are required. Our team will verify eligibility and arrange kit delivery.

First Name *

Last Name *

Email (Optional)

Phone *

Select Your State *

— Select State —

Date of Birth *

Primary Insurance *

Primary Insurance Number (Optional)

By submitting, you are giving Express Written Consent authorizing the Seniors Wellness Care team to contact you via voice, SMS, or email at the information provided regarding the following: confirming personal information, order submission or updates, and other healthcare benefits. The patient understands that these calls or messages may be generated by an automated dialer or messaging system. The patient is not required to provide consent as a condition of requesting or receiving any products or services. The patient also understands that this offer does not qualify them for any prize or reward. You understand that you can opt out at any time by replying STOP to the messages.

256-Bit Encrypted•HIPAA Compliant•No Surprise Billing

Need to submit orders by phone?

Call (866) 971-7353