Microbiology & Molecular Testing — Prescriber Request for Consult

How to Submit

Complete & Send Your Consult Request

1. Step 1

   Download the Form

   Use the "Download PDF" button below to save the Prescriber Request for Consult form to your device.

2. Step 2

   Complete & Sign

   Print the form, fill in all required patient and prescriber information, and sign where indicated.

3. Step 3

   Submit to Customicro Clinical Services

   Return the completed form to us using the contact details below.

   Fax:480-946-1345

   Email:clinical@customicro.com