Provider Kit Request Form

Request kits for your practice with the submission of this form. We provide every kit free of charge and we cover all shipping. Kits can be stored at room temperature. Each kit comes with forms, instructions, swabs, tub and holder.  A GnomeDX representative will contact you with the submission of this form to verify your request. For more information about the test process visit the test page

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Clinician Name *
Clinician Name
Are you a GnomeDX Provider?
If not apply here.
What test options are you interested in? *
Check all that apply