MindX One™ Blood Testing Prescription Form

Phone: 317-228-8590 | Fax: 317-663-2177 | Email: info@mindxsciences.com

351 W 10th St #101, Indianapolis, IN 46202

Note: Please complete all required fields marked with an asterisk (*). You can also download the PDF form and upload it here, fax it to 317-663-2177, or email to info@mindxsciences.com.

Prescriber Information

Prescriber Name*

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NPI*

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Prescriber Email*

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Office Contact Name*

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Office/Hospital Name*

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Address*

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City*

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State Zip*

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Phone*

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Fax

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Patient Information

Last Name*

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First Name*

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Gender*

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Date of Birth*

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Address*

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Apt.

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City*

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State*

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Zip*

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Phone*

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Email*

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Specimen Collection Location

We will send the patient a MindX Blood Test kit, pre-labeled for FedEx.

Collection Location*

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Testing Options

Please Choose Testing*

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Prescriber Signature

Prescriber Signature (type name)*

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Date*

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MindX Convergent Functional Information - Mental Health

(Check for "Yes", Leave blank for "No")

Previous Mental Health history

Previous Mental Health medications

Previous ER visits for Mental Health

Previous Hospitalizations for Mental Health

Previous suicidal ideation

Previous suicide attempts

Current substance abuse issues

Family history of Mental Health issues

On Disability, Service Connected for Veterans, or commitment/conservatorship

Patient's Employment Status

Employment Status

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Patient's Current Diagnosis

Primary

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Secondary

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Patient's Current Medications, Dosages, and Frequency of Administration

Medication

Dosage

Frequency