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Submitted URL: https://www.commdx.com/order-kits.php
Effective URL: https://commdx.com/diagnostic-solutions-order-form/
Submission: On October 13 via manual from US — Scanned from DE
Effective URL: https://commdx.com/diagnostic-solutions-order-form/
Submission: On October 13 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
POST /diagnostic-solutions-order-form/#gf_7
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_7" id="gform_7" action="/diagnostic-solutions-order-form/#gf_7">
<div class="gform_body gform-body">
<div id="gform_page_7_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_56" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_56">
<h2 class="gsection_title">Step 1: Get Started</h2>
</li>
<li id="field_7_57" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_7_57"><label class="gfield_label">Get Started:<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_7_57">
<li class="gchoice gchoice_7_57_0">
<input name="input_57" type="radio" value="Healthcare Provider: Ship to Practice" id="choice_7_57_0">
<label for="choice_7_57_0" id="label_7_57_0">Healthcare Provider: Ship to Practice</label>
</li>
<li class="gchoice gchoice_7_57_1">
<input name="input_57" type="radio" value="Healthcare Provider: Ship to Patient" id="choice_7_57_1">
<label for="choice_7_57_1" id="label_7_57_1">Healthcare Provider: Ship to Patient</label>
</li>
<li class="gchoice gchoice_7_57_2">
<input name="input_57" type="radio" value="Patient (IBSchek Self-Pay Only)" id="choice_7_57_2">
<label for="choice_7_57_2" id="label_7_57_2">Patient (IBSchek Self-Pay Only)</label>
</li>
</ul>
</div>
</li>
<li id="field_7_80" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_80" style="display: none;"><label class="gfield_label">I understand that I am
responsible to pay for IBSchek prior to the order being processed and shipped.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_7_80">
<li class="gchoice gchoice_7_80_0">
<input name="input_80" type="radio" value="I agree to pay the $99 test fee and would like to speak to customer service about processing my order." id="choice_7_80_0" disabled="disabled">
<label for="choice_7_80_0" id="label_7_80_0">I agree to pay the $99 test fee and would like to speak to customer service about processing my order.</label>
</li>
<li class="gchoice gchoice_7_80_1">
<input name="input_80" type="radio" value="I would like to speak to customer service about the payment plan options and financial hardship programs offered by CDI." id="choice_7_80_1" disabled="disabled">
<label for="choice_7_80_1" id="label_7_80_1">I would like to speak to customer service about the payment plan options and financial hardship programs offered by CDI.</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_7_80">NOTE: IBSchek is not available for residents of New York.</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_next_button_7_86" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_100" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_100">
<h2 class="gsection_title">Step 2 of 4: Provider & Practice Info</h2>
</li>
<li id="field_7_2" class="gfield gf_left_half gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible" data-js-reload="field_7_2"><label
class="gfield_label gfield_label_before_complex">Provider Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_7_2">
<span id="input_7_2_3_container" class="name_first">
<input type="text" name="input_2.3" id="input_7_2_3" value="" aria-required="true" placeholder="First">
<label for="input_7_2_3" class="hidden_sub_label screen-reader-text">First</label>
</span>
<span id="input_7_2_6_container" class="name_last">
<input type="text" name="input_2.6" id="input_7_2_6" value="" aria-required="true" placeholder="Last">
<label for="input_7_2_6" class="hidden_sub_label screen-reader-text">Last</label>
</span>
</div>
</li>
<li id="field_7_3" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_3"><label class="gfield_label" for="input_7_3">Provider NPI#<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_3" id="input_7_3" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_7_44" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_44"><label class="gfield_label" for="input_7_44">Provider Signature<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_7_44">*By signing this order form, the ordering practice represents that it has the appropriate prescribing rights to order the tests selected on this form.</div>
<div>
<div id="input_7_44_Container" class="gfield_signature_container ginput_container" style="height: 180px; z-index: 99; width: 0px;"><input type="hidden" class="gform_hidden" name="input_7_44_valid" id="input_7_44_valid"><canvas
id="input_7_44" width="0" height="180"
style="border-width: 1px; border-style: dashed; border-color: rgb(38, 38, 38); background-color: rgb(255, 255, 255); cursor: url("https://commdx.com/wp-content/plugins/gravityformssignature/includes/super_signature/pen.cur"), pointer; height: 180px; width: 0px;"></canvas>
</div>
<div id="input_7_44_toolbar" style="margin: 5px; position: relative; height: 20px; background-color: transparent; width: 0px;"><img id="input_7_44_resetbutton"
src="https://commdx.com/wp-content/plugins/gravityformssignature/includes/super_signature/refresh.png" style="cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent" alt="Clear Signature">
<div id="input_7_44_status" style="color: blue; height: 20px; width: auto; padding: 2px; font-family: verdana; font-size: 12px; float: left; margin-right: 30px; display: none;"></div><input type="hidden" id="input_7_44_data"
name="input_7_44_data" value=""><input type="hidden" id="input_7_44_data_smooth" name="input_7_44_data_smooth" value=""><input type="hidden" id="input_7_44_data_canvas" name="input_7_44_data_canvas" value=""><button type="button"
id="input_7_44_lockedReset" class="gform_signature_locked_reset"
style="display:none;height:24px;cursor:pointer;padding: 0 0 0 1.8em;opacity:0.75;font-size:0.813em;border:0;background: transparent url(data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHZpZXdCb3g9IjAgMCA0NDggNTEyIiBjbGFzcz0idW5kZWZpbmVkIj48cGF0aCBkPSJNNDAwIDIyNGgtMjR2LTcyQzM3NiA2OC4yIDMwNy44IDAgMjI0IDBTNzIgNjguMiA3MiAxNTJ2NzJINDhjLTI2LjUgMC00OCAyMS41LTQ4IDQ4djE5MmMwIDI2LjUgMjEuNSA0OCA0OCA0OGgzNTJjMjYuNSAwIDQ4LTIxLjUgNDgtNDhWMjcyYzAtMjYuNS0yMS41LTQ4LTQ4LTQ4em0tMTA0IDBIMTUydi03MmMwLTM5LjcgMzIuMy03MiA3Mi03MnM3MiAzMi4zIDcyIDcydjcyeiIgY2xhc3M9InVuZGVmaW5lZCIvPjwvc3ZnPg==) no-repeat left center;background-size:16px;">Reset
to re-sign.</button>
</div>
</div>
</li>
<li id="field_7_4" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_4"><label class="gfield_label gfield_label_before_complex">Practice Address<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address" id="input_7_4">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_7_4_1_container">
<input type="text" name="input_4.1" id="input_7_4_1" value="" aria-required="true">
<label for="input_7_4_1" id="input_7_4_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2" id="input_7_4_2_container">
<input type="text" name="input_4.2" id="input_7_4_2" value="" aria-required="false">
<label for="input_7_4_2" id="input_7_4_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city" id="input_7_4_3_container">
<input type="text" name="input_4.3" id="input_7_4_3" value="" aria-required="true">
<label for="input_7_4_3" id="input_7_4_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_7_4_4_container">
<select name="input_4.4" id="input_7_4_4" aria-required="true">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_7_4_4" id="input_7_4_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_7_4_5_container">
<input type="text" name="input_4.5" id="input_7_4_5" value="" aria-required="true">
<label for="input_7_4_5" id="input_7_4_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_4.6" id="input_7_4_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_7_49" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_49"><label class="gfield_label" for="input_7_49">Practice Name<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_49" id="input_7_49" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_7_6" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_6"><label class="gfield_label" for="input_7_6">Practice Email<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_6" id="input_7_6" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_7_50" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_50"><label class="gfield_label" for="input_7_50">Practice Phone<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_50" id="input_7_50" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_7_51" class="gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_51"><label class="gfield_label" for="input_7_51">Practice Fax</label>
<div class="ginput_container ginput_container_phone"><input name="input_51" id="input_7_51" type="text" value="" class="medium" aria-invalid="false"></div>
</li>
<li id="field_7_52" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_52"><label class="gfield_label gfield_label_before_complex">Please send results
via<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_52">
<li class="gchoice gchoice_7_52_1">
<input class="gfield-choice-input" name="input_52.1" type="checkbox" value="Fax" id="choice_7_52_1">
<label for="choice_7_52_1" id="label_7_52_1">Fax</label>
</li>
<li class="gchoice gchoice_7_52_2">
<input class="gfield-choice-input" name="input_52.2" type="checkbox" value="Email" id="choice_7_52_2">
<label for="choice_7_52_2" id="label_7_52_2">Email</label>
</li>
<li class="gchoice gchoice_7_52_3">
<input class="gfield-choice-input" name="input_52.3" type="checkbox" value="Web Portal" id="choice_7_52_3">
<label for="choice_7_52_3" id="label_7_52_3">Web Portal</label>
</li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_58" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("1"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("1"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_58"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("3"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("3"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_59" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_59">
<h2 class="gsection_title">Step 3 of 3: Diagnostic Solutions (Ship to Practice)</h2>
</li>
<li id="field_7_37" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_37"><label class="gfield_label gfield_label_before_complex">Sample Collection
Kits<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_37">
<li class="gchoice gchoice_7_37_1">
<input class="gfield-choice-input" name="input_37.1" type="checkbox" value="SIBO 10 Tube Lactulose" id="choice_7_37_1" aria-describedby="gfield_description_7_37">
<label for="choice_7_37_1" id="label_7_37_1"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon.png" width="25px"> SIBO 10 Tube Lactulose</label>
</li>
<li class="gchoice gchoice_7_37_2">
<input class="gfield-choice-input" name="input_37.2" type="checkbox" value="SIBO 10 Tube Glucose" id="choice_7_37_2">
<label for="choice_7_37_2" id="label_7_37_2"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon.png" width="25px"> SIBO 10 Tube Glucose</label>
</li>
<li class="gchoice gchoice_7_37_3">
<input class="gfield-choice-input" name="input_37.3" type="checkbox" value="SIBO 6 Tube Lactulose (pediatric use)" id="choice_7_37_3">
<label for="choice_7_37_3" id="label_7_37_3"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon.png" width="25px"> SIBO 6 Tube Lactulose (pediatric use)</label>
</li>
<li class="gchoice gchoice_7_37_4">
<input class="gfield-choice-input" name="input_37.4" type="checkbox" value="Lactose 6 Tube" id="choice_7_37_4">
<label for="choice_7_37_4" id="label_7_37_4"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon-yellow.png" width="25px"> Lactose 6 Tube</label>
</li>
<li class="gchoice gchoice_7_37_5">
<input class="gfield-choice-input" name="input_37.5" type="checkbox" value="Fructose 6 Tube" id="choice_7_37_5">
<label for="choice_7_37_5" id="label_7_37_5"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon-orange.png" width="25px"> Fructose 6 Tube</label>
</li>
<li class="gchoice gchoice_7_37_6">
<input class="gfield-choice-input" name="input_37.6" type="checkbox" value="Sucrose 6 Tube" id="choice_7_37_6">
<label for="choice_7_37_6" id="label_7_37_6"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon-pink.png" width="25px"> Sucrose 6 Tube</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_7_37">NOTE: Only breath tests can be ordered as bulk shipments to practices. If you are interested in ordering multiple IBSchek kits to distribute from your office, please contact the
CDI provider services team.</div>
</li>
<li id="field_7_38" class="gfield gf_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_38" style="display: none;"><label class="gfield_label" for="input_7_38">How
many SIBO 10 Tube Lactulose kits?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_7_38" type="text" value="1" class="medium" maxlength="2" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter warningTextareaInfo" aria-live="polite">1 of 2 max characters</div>
</div>
</li>
<li id="field_7_39" class="gfield gf_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_39" style="display: none;"><label class="gfield_label" for="input_7_39">How
many SIBO 10 Tube Glucose kits?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_39" id="input_7_39" type="text" value="1" class="medium" maxlength="2" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter warningTextareaInfo" aria-live="polite">1 of 2 max characters</div>
</div>
</li>
<li id="field_7_40" class="gfield gf_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_40" style="display: none;"><label class="gfield_label" for="input_7_40">How
many SIBO 6 Tube Lactulose (pediatric use) kits?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_40" id="input_7_40" type="text" value="1" class="medium" maxlength="2" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter warningTextareaInfo" aria-live="polite">1 of 2 max characters</div>
</div>
</li>
<li id="field_7_41" class="gfield gf_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_41" style="display: none;"><label class="gfield_label" for="input_7_41">How
many Sucrose 6 Tube kits?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_41" id="input_7_41" type="text" value="1" class="medium" maxlength="2" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter warningTextareaInfo" aria-live="polite">1 of 2 max characters</div>
</div>
</li>
<li id="field_7_42" class="gfield gf_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_42" style="display: none;"><label class="gfield_label" for="input_7_42">How
many Lactose 6 Tube kits?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_42" id="input_7_42" type="text" value="1" class="medium" maxlength="2" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter warningTextareaInfo" aria-live="polite">1 of 2 max characters</div>
</div>
</li>
<li id="field_7_43" class="gfield gf_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_43" style="display: none;"><label class="gfield_label" for="input_7_43">How
many Fructose 6 Tube kits?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_43" id="input_7_43" type="text" value="1" class="medium" maxlength="2" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter warningTextareaInfo" aria-live="polite">1 of 2 max characters</div>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_60" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_60"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("4"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("4"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_61" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_61">
<h2 class="gsection_title">Step 3 of 4: Diagnostic Solutions (Ship to Patient)</h2>
</li>
<li id="field_7_63" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_63"><label class="gfield_label gfield_label_before_complex">Sample Collection
Kits<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_63">
<li class="gchoice gchoice_7_63_1">
<input class="gfield-choice-input" name="input_63.1" type="checkbox" value="SIBO 10 Tube Lactulose" id="choice_7_63_1" aria-describedby="gfield_description_7_63">
<label for="choice_7_63_1" id="label_7_63_1"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon.png" width="25px"> SIBO 10 Tube Lactulose</label>
</li>
<li class="gchoice gchoice_7_63_2">
<input class="gfield-choice-input" name="input_63.2" type="checkbox" value="SIBO 10 Tube Glucose" id="choice_7_63_2">
<label for="choice_7_63_2" id="label_7_63_2"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon.png" width="25px"> SIBO 10 Tube Glucose</label>
</li>
<li class="gchoice gchoice_7_63_3">
<input class="gfield-choice-input" name="input_63.3" type="checkbox" value="SIBO 6 Tube Lactulose (pediatric use)" id="choice_7_63_3">
<label for="choice_7_63_3" id="label_7_63_3"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon.png" width="25px"> SIBO 6 Tube Lactulose (pediatric use)</label>
</li>
<li class="gchoice gchoice_7_63_4">
<input class="gfield-choice-input" name="input_63.4" type="checkbox" value="IBSchek Capillary Collection Kit" id="choice_7_63_4">
<label for="choice_7_63_4" id="label_7_63_4"><img src="https://commdx.com/wp-content/uploads/2020/11/capillary-test-icon-purple.png" width="25px"> IBSchek Capillary Collection Kit</label>
</li>
<li class="gchoice gchoice_7_63_5">
<input class="gfield-choice-input" name="input_63.5" type="checkbox" value="Lactose 6 Tube" id="choice_7_63_5">
<label for="choice_7_63_5" id="label_7_63_5"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon-yellow.png" width="25px"> Lactose 6 Tube</label>
</li>
<li class="gchoice gchoice_7_63_6">
<input class="gfield-choice-input" name="input_63.6" type="checkbox" value="Fructose 6 Tube" id="choice_7_63_6">
<label for="choice_7_63_6" id="label_7_63_6"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon-orange.png" width="25px"> Fructose 6 Tube</label>
</li>
<li class="gchoice gchoice_7_63_7">
<input class="gfield-choice-input" name="input_63.7" type="checkbox" value="Sucrose 6 Tube" id="choice_7_63_7">
<label for="choice_7_63_7" id="label_7_63_7"><img src="https://commdx.com/wp-content/uploads/2020/11/breath-test-icon-pink.png" width="25px"> Sucrose 6 Tube</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_7_63">NOTE: IBSchek cannot be ordered by practices located in New York.</div>
</li>
<li id="field_7_88" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_7_88"><label class="gfield_label gfield_label_before_complex">Multiple Kits?</label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_88">
<li class="gchoice gchoice_7_88_1">
<input class="gfield-choice-input" name="input_88.1" type="checkbox" value="My patient needs 2 of the same type of kit for pre and post treatment." id="choice_7_88_1">
<label for="choice_7_88_1" id="label_7_88_1">My patient needs 2 of the same type of kit for pre and post treatment.</label>
</li>
</ul>
</div>
</li>
<li id="field_7_90" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_90" style="display: none;"><label class="gfield_label" for="input_7_90">For which
kit(s)?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_90" id="input_7_90" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_62" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("3"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("3"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_62"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("5"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("5"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_101" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_101">
<h2 class="gsection_title">Step 4 of 4: Patient Info</h2>
</li>
<li id="field_7_28" class="gfield gf_left_half gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible" data-js-reload="field_7_28"><label
class="gfield_label gfield_label_before_complex">Patient Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_7_28">
<span id="input_7_28_3_container" class="name_first">
<input type="text" name="input_28.3" id="input_7_28_3" value="" aria-required="true" placeholder="First">
<label for="input_7_28_3" class="hidden_sub_label screen-reader-text">First</label>
</span>
<span id="input_7_28_6_container" class="name_last">
<input type="text" name="input_28.6" id="input_7_28_6" value="" aria-required="true" placeholder="Last">
<label for="input_7_28_6" class="hidden_sub_label screen-reader-text">Last</label>
</span>
</div>
</li>
<li id="field_7_10" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_10"><label class="gfield_label">Patient Date of Birth<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div id="input_7_10" class="ginput_container ginput_complex">
<div class="clear-multi">
<div class="gfield_date_dropdown_month ginput_container ginput_container_date" id="input_7_10_1_container"><select name="input_10[]" id="input_7_10_1" aria-required="true">
<option value="">Month</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
<div class="gfield_date_dropdown_day ginput_container ginput_container_date" id="input_7_10_2_container"><select name="input_10[]" id="input_7_10_2" aria-required="true">
<option value="">Day</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></div>
<div class="gfield_date_dropdown_year ginput_container ginput_container_date" id="input_7_10_3_container"><select name="input_10[]" id="input_7_10_3" aria-required="true">
<option value="">Year</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
</select></div>
</div>
</div>
</li>
<li id="field_7_11" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_11"><label class="gfield_label gfield_label_before_complex">Patient Shipping
Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address" id="input_7_11">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_7_11_1_container">
<input type="text" name="input_11.1" id="input_7_11_1" value="" aria-required="true">
<label for="input_7_11_1" id="input_7_11_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2" id="input_7_11_2_container">
<input type="text" name="input_11.2" id="input_7_11_2" value="" aria-required="false">
<label for="input_7_11_2" id="input_7_11_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city" id="input_7_11_3_container">
<input type="text" name="input_11.3" id="input_7_11_3" value="" aria-required="true">
<label for="input_7_11_3" id="input_7_11_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_7_11_4_container">
<select name="input_11.4" id="input_7_11_4" aria-required="true">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_7_11_4" id="input_7_11_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_7_11_5_container">
<input type="text" name="input_11.5" id="input_7_11_5" value="" aria-required="true">
<label for="input_7_11_5" id="input_7_11_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_11.6" id="input_7_11_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_7_29" class="gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_29" style="display: none;"><label class="gfield_label" for="input_7_29">Patient Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_29" id="input_7_29" type="text" value="" class="medium" aria-invalid="false" aria-describedby="gfield_description_7_29" disabled="disabled">
</div>
<div class="gfield_description" id="gfield_description_7_29">Entering a patient email address is highly encouraged as it allows CDI to provide direct patient outreach and support during the test-taking process.</div>
</li>
<li id="field_7_91" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_91" style="display: none;"><label class="gfield_label"
for="input_7_91">Patient Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_91" id="input_7_91" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled="disabled">
</div>
</li>
<li id="field_7_54" class="gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_54"><label class="gfield_label" for="input_7_54">Patient Phone</label>
<div class="ginput_container ginput_container_phone"><input name="input_54" id="input_7_54" type="text" value="" class="medium" aria-invalid="false"></div>
</li>
<li id="field_7_18" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_18" style="display: none;"><label
class="gfield_label gfield_label_before_complex">ICD-10 Code for Breath Tests<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_7_18">* These codes are listed as a convenience. Ordering practitioners should report the diagnosis code(s) that best describe the reason for performing the test, regardless of
whether the code is listed above or not.</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_18">
<li class="gchoice gchoice_7_18_1">
<input class="gfield-choice-input" name="input_18.1" type="checkbox" value="R10.84 Generalized abdominal pain" id="choice_7_18_1" aria-describedby="gfield_description_7_18" disabled="disabled">
<label for="choice_7_18_1" id="label_7_18_1">R10.84 Generalized abdominal pain</label>
</li>
<li class="gchoice gchoice_7_18_2">
<input class="gfield-choice-input" name="input_18.2" type="checkbox" value="R14.0 Abdominal distension (gaseous)" id="choice_7_18_2" disabled="disabled">
<label for="choice_7_18_2" id="label_7_18_2">R14.0 Abdominal distension (gaseous)</label>
</li>
<li class="gchoice gchoice_7_18_3">
<input class="gfield-choice-input" name="input_18.3" type="checkbox" value="R19.7 Diarrhea, unspecified" id="choice_7_18_3" disabled="disabled">
<label for="choice_7_18_3" id="label_7_18_3">R19.7 Diarrhea, unspecified</label>
</li>
<li class="gchoice gchoice_7_18_4">
<input class="gfield-choice-input" name="input_18.4" type="checkbox" value="K59.0 Constipation" id="choice_7_18_4" disabled="disabled">
<label for="choice_7_18_4" id="label_7_18_4">K59.0 Constipation</label>
</li>
<li class="gchoice gchoice_7_18_5">
<input class="gfield-choice-input" name="input_18.5" type="checkbox" value="K58.0 Irritable Bowel Syndrome with diarrhea" id="choice_7_18_5" disabled="disabled">
<label for="choice_7_18_5" id="label_7_18_5">K58.0 Irritable Bowel Syndrome with diarrhea</label>
</li>
<li class="gchoice gchoice_7_18_6">
<input class="gfield-choice-input" name="input_18.6" type="checkbox" value="A04.9 Bacterial intestinal infection, unspecified" id="choice_7_18_6" disabled="disabled">
<label for="choice_7_18_6" id="label_7_18_6">A04.9 Bacterial intestinal infection, unspecified</label>
</li>
<li class="gchoice gchoice_7_18_7">
<input class="gfield-choice-input" name="input_18.7" type="checkbox" value="Other(s):" id="choice_7_18_7" disabled="disabled">
<label for="choice_7_18_7" id="label_7_18_7">Other(s):</label>
</li>
</ul>
</div>
</li>
<li id="field_7_53" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_7_53" style="display: none;"><label class="gfield_label"
for="input_7_53">Additional ICD-10 Codes for Breath Tests<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_53" id="input_7_53" type="text" value="" class="large" placeholder="Additional ICD-10 Codes for Breath Tests" aria-required="true" aria-invalid="false"
disabled="disabled"> </div>
</li>
<li id="field_7_94" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_94" style="display: none;"><label
class="gfield_label gfield_label_before_complex">ICD-10 Code for IBSchek<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_7_94">* These codes are listed as a convenience. Ordering practitioners should report the diagnosis code(s) that best describe the reason for performing the test, regardless of
whether the code is listed above or not.</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_94">
<li class="gchoice gchoice_7_94_1">
<input class="gfield-choice-input" name="input_94.1" type="checkbox" value="K58.0 Irritable Bowel Syndrome with diarrhea" id="choice_7_94_1" aria-describedby="gfield_description_7_94" disabled="disabled">
<label for="choice_7_94_1" id="label_7_94_1">K58.0 Irritable Bowel Syndrome with diarrhea</label>
</li>
<li class="gchoice gchoice_7_94_2">
<input class="gfield-choice-input" name="input_94.2" type="checkbox" value="Other(s):" id="choice_7_94_2" disabled="disabled">
<label for="choice_7_94_2" id="label_7_94_2">Other(s):</label>
</li>
</ul>
</div>
</li>
<li id="field_7_115" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_7_115" style="display: none;"><label class="gfield_label"
for="input_7_115">Additional ICD-10 Codes for IBSchek<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_115" id="input_7_115" type="text" value="" class="large" placeholder="Additional ICD-10 Codes for IBSchek" aria-required="true" aria-invalid="false"
disabled="disabled"> </div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_107" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("4"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("4"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_107"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("6"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("6"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_108" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_108" style="display: none;">
<h2 class="gsection_title">Step 2 of 4: Patient Info</h2>
</li>
<li id="field_7_109" class="gfield gf_left_half gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible" data-js-reload="field_7_109" style="display: none;"><label
class="gfield_label gfield_label_before_complex">Patient Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_7_109">
<span id="input_7_109_3_container" class="name_first">
<input type="text" name="input_109.3" id="input_7_109_3" value="" aria-required="true" placeholder="First" disabled="disabled">
<label for="input_7_109_3" class="hidden_sub_label screen-reader-text">First</label>
</span>
<span id="input_7_109_6_container" class="name_last">
<input type="text" name="input_109.6" id="input_7_109_6" value="" aria-required="true" placeholder="Last" disabled="disabled">
<label for="input_7_109_6" class="hidden_sub_label screen-reader-text">Last</label>
</span>
</div>
</li>
<li id="field_7_110" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_110" style="display: none;"><label class="gfield_label">Patient Date
of Birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div id="input_7_110" class="ginput_container ginput_complex">
<div class="clear-multi">
<div class="gfield_date_dropdown_month ginput_container ginput_container_date" id="input_7_110_1_container"><select name="input_110[]" id="input_7_110_1" aria-required="true" disabled="disabled">
<option value="">Month</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
<div class="gfield_date_dropdown_day ginput_container ginput_container_date" id="input_7_110_2_container"><select name="input_110[]" id="input_7_110_2" aria-required="true" disabled="disabled">
<option value="">Day</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></div>
<div class="gfield_date_dropdown_year ginput_container ginput_container_date" id="input_7_110_3_container"><select name="input_110[]" id="input_7_110_3" aria-required="true" disabled="disabled">
<option value="">Year</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
</select></div>
</div>
</div>
</li>
<li id="field_7_111" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_111" style="display: none;"><label
class="gfield_label gfield_label_before_complex">Patient Shipping Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address" id="input_7_111">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_7_111_1_container">
<input type="text" name="input_111.1" id="input_7_111_1" value="" aria-required="true" disabled="disabled">
<label for="input_7_111_1" id="input_7_111_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2" id="input_7_111_2_container">
<input type="text" name="input_111.2" id="input_7_111_2" value="" aria-required="false" disabled="disabled">
<label for="input_7_111_2" id="input_7_111_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city" id="input_7_111_3_container">
<input type="text" name="input_111.3" id="input_7_111_3" value="" aria-required="true" disabled="disabled">
<label for="input_7_111_3" id="input_7_111_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_7_111_4_container">
<select name="input_111.4" id="input_7_111_4" aria-required="true" disabled="disabled">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_7_111_4" id="input_7_111_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_7_111_5_container">
<input type="text" name="input_111.5" id="input_7_111_5" value="" aria-required="true" disabled="disabled">
<label for="input_7_111_5" id="input_7_111_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_111.6" id="input_7_111_6" value="United States" disabled="disabled">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_7_112" class="gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_112" style="display: none;"><label class="gfield_label" for="input_7_112">Patient Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_112" id="input_7_112" type="text" value="" class="medium" aria-invalid="false" aria-describedby="gfield_description_7_112" disabled="disabled">
</div>
<div class="gfield_description" id="gfield_description_7_112">Entering a patient email address is highly encouraged as it allows CDI to provide direct patient outreach and support during the test-taking process.</div>
</li>
<li id="field_7_113" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_113" style="display: none;"><label class="gfield_label"
for="input_7_113">Patient Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_113" id="input_7_113" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled="disabled">
</div>
</li>
<li id="field_7_114" class="gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_114" style="display: none;"><label class="gfield_label" for="input_7_114">Patient Phone</label>
<div class="ginput_container ginput_container_phone"><input name="input_114" id="input_7_114" type="text" value="" class="medium" aria-invalid="false" disabled="disabled"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_85" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("5"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("5"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_85"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("7"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("7"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_72" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_72">
<h2 class="gsection_title">Step 3 of 4: IBSchek Patient Questionnaire</h2>
</li>
<li id="field_7_73" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_73"><label class="gfield_label">Would you like to find out if you have
certain types of Irritable Bowel Syndrome by taking a test?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_7_73">
<li class="gchoice gchoice_7_73_0">
<input name="input_73" type="radio" value="Yes" id="choice_7_73_0">
<label for="choice_7_73_0" id="label_7_73_0">Yes</label>
</li>
<li class="gchoice gchoice_7_73_1">
<input name="input_73" type="radio" value="No" id="choice_7_73_1">
<label for="choice_7_73_1" id="label_7_73_1">No</label>
</li>
</ul>
</div>
</li>
<li id="field_7_74" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_74"><label class="gfield_label">Have you ever been tested for IBS-D or
IBS-M?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_7_74">
<li class="gchoice gchoice_7_74_0">
<input name="input_74" type="radio" value="Yes" id="choice_7_74_0">
<label for="choice_7_74_0" id="label_7_74_0">Yes</label>
</li>
<li class="gchoice gchoice_7_74_1">
<input name="input_74" type="radio" value="No" id="choice_7_74_1">
<label for="choice_7_74_1" id="label_7_74_1">No</label>
</li>
</ul>
</div>
</li>
<li id="field_7_75" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_75"><label class="gfield_label gfield_label_before_complex">Have you had
any of the following in the PAST 3 MONTHS?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_7_75">(Check all that apply)</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_75">
<li class="gchoice gchoice_7_75_1">
<input class="gfield-choice-input" name="input_75.1" type="checkbox" value="Abdominal pain or discomfort" id="choice_7_75_1" aria-describedby="gfield_description_7_75">
<label for="choice_7_75_1" id="label_7_75_1">Abdominal pain or discomfort</label>
</li>
<li class="gchoice gchoice_7_75_2">
<input class="gfield-choice-input" name="input_75.2" type="checkbox" value="Diarrhea" id="choice_7_75_2">
<label for="choice_7_75_2" id="label_7_75_2">Diarrhea</label>
</li>
<li class="gchoice gchoice_7_75_3">
<input class="gfield-choice-input" name="input_75.3" type="checkbox" value="Constipation" id="choice_7_75_3">
<label for="choice_7_75_3" id="label_7_75_3">Constipation</label>
</li>
<li class="gchoice gchoice_7_75_4">
<input class="gfield-choice-input" name="input_75.4" type="checkbox" value="Constipation alternating with diarrhea" id="choice_7_75_4">
<label for="choice_7_75_4" id="label_7_75_4">Constipation alternating with diarrhea</label>
</li>
<li class="gchoice gchoice_7_75_5">
<input class="gfield-choice-input" name="input_75.5" type="checkbox" value="Gas" id="choice_7_75_5">
<label for="choice_7_75_5" id="label_7_75_5">Gas</label>
</li>
<li class="gchoice gchoice_7_75_6">
<input class="gfield-choice-input" name="input_75.6" type="checkbox" value="Abdominal bloating" id="choice_7_75_6">
<label for="choice_7_75_6" id="label_7_75_6">Abdominal bloating</label>
</li>
<li class="gchoice gchoice_7_75_7">
<input class="gfield-choice-input" name="input_75.7" type="checkbox" value="Belly pains or cramps, usually in the lower half of the belly, that get worse after meals and feel better after a bowel movement" id="choice_7_75_7">
<label for="choice_7_75_7" id="label_7_75_7">Belly pains or cramps, usually in the lower half of the belly, that get worse after meals and feel better after a bowel movement</label>
</li>
<li class="gchoice gchoice_7_75_8">
<input class="gfield-choice-input" name="input_75.8" type="checkbox" value="Change in bowel movement frequency (more than three bowel movements per day, diarrhea or loose stool, or less than three bowel movements per week)"
id="choice_7_75_8">
<label for="choice_7_75_8" id="label_7_75_8">Change in bowel movement frequency (more than three bowel movements per day, diarrhea or loose stool, or less than three bowel movements per week)</label>
</li>
<li class="gchoice gchoice_7_75_9">
<input class="gfield-choice-input" name="input_75.9" type="checkbox" value="Change in appearance of stool: hard pellets, not well formed, undigested food, liquid, mucus" id="choice_7_75_9">
<label for="choice_7_75_9" id="label_7_75_9">Change in appearance of stool: hard pellets, not well formed, undigested food, liquid, mucus</label>
</li>
<li class="gchoice gchoice_7_75_11">
<input class="gfield-choice-input" name="input_75.11" type="checkbox" value="Harder or looser stools than normal (pellets or flat ribbon stools)" id="choice_7_75_11">
<label for="choice_7_75_11" id="label_7_75_11">Harder or looser stools than normal (pellets or flat ribbon stools)</label>
</li>
<li class="gchoice gchoice_7_75_12">
<input class="gfield-choice-input" name="input_75.12" type="checkbox" value="Digestive issues beginning after an episode of gastroenteritis more commonly known as food poisoning" id="choice_7_75_12">
<label for="choice_7_75_12" id="label_7_75_12">Digestive issues beginning after an episode of gastroenteritis more commonly known as food poisoning</label>
</li>
<li class="gchoice gchoice_7_75_13">
<input class="gfield-choice-input" name="input_75.13" type="checkbox" value="None of the above" id="choice_7_75_13">
<label for="choice_7_75_13" id="label_7_75_13">None of the above</label>
</li>
</ul>
</div>
</li>
<li id="field_7_76" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_76"><label class="gfield_label gfield_label_before_complex">Have you
had any of the following in the PAST 12 MONTHS<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_7_76">(Check all that apply)</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_76">
<li class="gchoice gchoice_7_76_1">
<input class="gfield-choice-input" name="input_76.1" type="checkbox" value="Abdominal pain or discomfort" id="choice_7_76_1" aria-describedby="gfield_description_7_76">
<label for="choice_7_76_1" id="label_7_76_1">Abdominal pain or discomfort</label>
</li>
<li class="gchoice gchoice_7_76_2">
<input class="gfield-choice-input" name="input_76.2" type="checkbox" value="Diarrhea" id="choice_7_76_2">
<label for="choice_7_76_2" id="label_7_76_2">Diarrhea</label>
</li>
<li class="gchoice gchoice_7_76_3">
<input class="gfield-choice-input" name="input_76.3" type="checkbox" value="Constipation" id="choice_7_76_3">
<label for="choice_7_76_3" id="label_7_76_3">Constipation</label>
</li>
<li class="gchoice gchoice_7_76_4">
<input class="gfield-choice-input" name="input_76.4" type="checkbox" value="Constipation alternating with diarrhea" id="choice_7_76_4">
<label for="choice_7_76_4" id="label_7_76_4">Constipation alternating with diarrhea</label>
</li>
<li class="gchoice gchoice_7_76_5">
<input class="gfield-choice-input" name="input_76.5" type="checkbox" value="Gas" id="choice_7_76_5">
<label for="choice_7_76_5" id="label_7_76_5">Gas</label>
</li>
<li class="gchoice gchoice_7_76_6">
<input class="gfield-choice-input" name="input_76.6" type="checkbox" value="Abdominal bloating" id="choice_7_76_6">
<label for="choice_7_76_6" id="label_7_76_6">Abdominal bloating</label>
</li>
<li class="gchoice gchoice_7_76_7">
<input class="gfield-choice-input" name="input_76.7" type="checkbox" value="Belly pains or cramps, usually in the lower half of the belly, that get worse after meals and feel better after a bowel movement" id="choice_7_76_7">
<label for="choice_7_76_7" id="label_7_76_7">Belly pains or cramps, usually in the lower half of the belly, that get worse after meals and feel better after a bowel movement</label>
</li>
<li class="gchoice gchoice_7_76_8">
<input class="gfield-choice-input" name="input_76.8" type="checkbox" value="Change in bowel movement frequency (more than three bowel movements per day, diarrhea or loose stool, or less than three bowel movements per week)"
id="choice_7_76_8">
<label for="choice_7_76_8" id="label_7_76_8">Change in bowel movement frequency (more than three bowel movements per day, diarrhea or loose stool, or less than three bowel movements per week)</label>
</li>
<li class="gchoice gchoice_7_76_9">
<input class="gfield-choice-input" name="input_76.9" type="checkbox" value="Change in appearance of stool: hard pellets, not well formed, undigested food, liquid, mucus" id="choice_7_76_9">
<label for="choice_7_76_9" id="label_7_76_9">Change in appearance of stool: hard pellets, not well formed, undigested food, liquid, mucus</label>
</li>
<li class="gchoice gchoice_7_76_11">
<input class="gfield-choice-input" name="input_76.11" type="checkbox" value="Harder or looser stools than normal (pellets or flat ribbon stools)" id="choice_7_76_11">
<label for="choice_7_76_11" id="label_7_76_11">Harder or looser stools than normal (pellets or flat ribbon stools)</label>
</li>
<li class="gchoice gchoice_7_76_12">
<input class="gfield-choice-input" name="input_76.12" type="checkbox" value="Digestive issues beginning after an episode of gastroenteritis more commonly known as food poisoning" id="choice_7_76_12">
<label for="choice_7_76_12" id="label_7_76_12">Digestive issues beginning after an episode of gastroenteritis more commonly known as food poisoning</label>
</li>
<li class="gchoice gchoice_7_76_13">
<input class="gfield-choice-input" name="input_76.13" type="checkbox" value="None of the above" id="choice_7_76_13">
<label for="choice_7_76_13" id="label_7_76_13">None of the above</label>
</li>
</ul>
</div>
</li>
<li id="field_7_77" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_7_77"><label class="gfield_label gfield_label_before_complex">Have you
ever been diagnosed with:<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_7_77">(Check all that apply)</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_7_77">
<li class="gchoice gchoice_7_77_1">
<input class="gfield-choice-input" name="input_77.1" type="checkbox" value="Celiac Disease" id="choice_7_77_1" aria-describedby="gfield_description_7_77">
<label for="choice_7_77_1" id="label_7_77_1">Celiac Disease</label>
</li>
<li class="gchoice gchoice_7_77_2">
<input class="gfield-choice-input" name="input_77.2" type="checkbox" value="Clodstridium Difficile" id="choice_7_77_2">
<label for="choice_7_77_2" id="label_7_77_2">Clodstridium Difficile</label>
</li>
<li class="gchoice gchoice_7_77_3">
<input class="gfield-choice-input" name="input_77.3" type="checkbox" value="Crohn's Disease" id="choice_7_77_3">
<label for="choice_7_77_3" id="label_7_77_3">Crohn's Disease</label>
</li>
<li class="gchoice gchoice_7_77_4">
<input class="gfield-choice-input" name="input_77.4" type="checkbox" value="Dyspepsia" id="choice_7_77_4">
<label for="choice_7_77_4" id="label_7_77_4">Dyspepsia</label>
</li>
<li class="gchoice gchoice_7_77_5">
<input class="gfield-choice-input" name="input_77.5" type="checkbox" value="Dysphagia" id="choice_7_77_5">
<label for="choice_7_77_5" id="label_7_77_5">Dysphagia</label>
</li>
<li class="gchoice gchoice_7_77_6">
<input class="gfield-choice-input" name="input_77.6" type="checkbox" value="Food allergies" id="choice_7_77_6">
<label for="choice_7_77_6" id="label_7_77_6">Food allergies</label>
</li>
<li class="gchoice gchoice_7_77_7">
<input class="gfield-choice-input" name="input_77.7" type="checkbox" value="Gastroparesis" id="choice_7_77_7">
<label for="choice_7_77_7" id="label_7_77_7">Gastroparesis</label>
</li>
<li class="gchoice gchoice_7_77_8">
<input class="gfield-choice-input" name="input_77.8" type="checkbox" value="Inflammatory Bowel Disease (IBD)" id="choice_7_77_8">
<label for="choice_7_77_8" id="label_7_77_8">Inflammatory Bowel Disease (IBD)</label>
</li>
<li class="gchoice gchoice_7_77_9">
<input class="gfield-choice-input" name="input_77.9" type="checkbox" value="Irritable Bowel Syndrome (IBS)" id="choice_7_77_9">
<label for="choice_7_77_9" id="label_7_77_9">Irritable Bowel Syndrome (IBS)</label>
</li>
<li class="gchoice gchoice_7_77_11">
<input class="gfield-choice-input" name="input_77.11" type="checkbox" value="Lactose intolerance" id="choice_7_77_11">
<label for="choice_7_77_11" id="label_7_77_11">Lactose intolerance</label>
</li>
<li class="gchoice gchoice_7_77_12">
<input class="gfield-choice-input" name="input_77.12" type="checkbox" value="Malabsorption" id="choice_7_77_12">
<label for="choice_7_77_12" id="label_7_77_12">Malabsorption</label>
</li>
<li class="gchoice gchoice_7_77_13">
<input class="gfield-choice-input" name="input_77.13" type="checkbox" value="Small Intestinal Bacterial Overgrowth" id="choice_7_77_13">
<label for="choice_7_77_13" id="label_7_77_13">Small Intestinal Bacterial Overgrowth</label>
</li>
<li class="gchoice gchoice_7_77_14">
<input class="gfield-choice-input" name="input_77.14" type="checkbox" value="None of the above" id="choice_7_77_14">
<label for="choice_7_77_14" id="label_7_77_14">None of the above</label>
</li>
</ul>
</div>
</li>
<li id="field_7_78" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_78"><label class="gfield_label">When was your last doctors
appointment?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_7_78">
<li class="gchoice gchoice_7_78_0">
<input name="input_78" type="radio" value="0 - 1 month" id="choice_7_78_0">
<label for="choice_7_78_0" id="label_7_78_0">0 - 1 month</label>
</li>
<li class="gchoice gchoice_7_78_1">
<input name="input_78" type="radio" value="2 - 3 months" id="choice_7_78_1">
<label for="choice_7_78_1" id="label_7_78_1">2 - 3 months</label>
</li>
<li class="gchoice gchoice_7_78_2">
<input name="input_78" type="radio" value="3 - 6 months" id="choice_7_78_2">
<label for="choice_7_78_2" id="label_7_78_2">3 - 6 months</label>
</li>
<li class="gchoice gchoice_7_78_3">
<input name="input_78" type="radio" value="6+ months" id="choice_7_78_3">
<label for="choice_7_78_3" id="label_7_78_3">6+ months</label>
</li>
<li class="gchoice gchoice_7_78_4">
<input name="input_78" type="radio" value="None of the above" id="choice_7_78_4">
<label for="choice_7_78_4" id="label_7_78_4">None of the above</label>
</li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_92" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("6"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("6"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_92"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("8"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("8"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_79" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_79">
<h2 class="gsection_title">Step 4 of 4: Self-Pay Billing Info</h2>
</li>
<li id="field_7_118" class="gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_118" style="display: none;">Thank
you for your interest in IBSchek. Please review and submit your order request. Our customer service team will be in contact with you shortly to process this order.</li>
<li id="field_7_106" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_106" style="display: none;">CDI offers convenient
payment plans and financial hardship programs for qualifying patients. The maximum out-of-pocket cost for IBSchek is $99 for patients that pay promptly in accordance with CDI patient billing policies and programs. Please submit your order
and our customer service team will reach out to discuss payment options.</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_103" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_7").val("7"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("7"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_103"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_7").val("9"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("9"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_7_9" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_7_104" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_104">
<h2 class="gsection_title">Review & Submit Order</h2>
</li>
<li id="field_7_105" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_105">{all_fields:nohidden}</li>
<li id="field_7_116" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_116">
<div class="ginput_container ginput_container_text"><input name="input_116" id="input_7_116" type="hidden" class="gform_hidden" aria-invalid="false"
value="https://app-3QNRRRN4L0.marketingautomation.services/webforms/receivePostback/MzawMLE0NDKxAAA/"></div>
</li>
<li id="field_7_117" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_7_117">
<div class="ginput_container ginput_container_text"><input name="input_117" id="input_7_117" type="hidden" class="gform_hidden" aria-invalid="false" value="65c1f79d-c8b9-4c09-ad3e-60bcf0de0cc8"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_7" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_7"]){return false;} window["gf_submitting_7"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_7"]){return false;} window["gf_submitting_7"]=true; jQuery("#gform_7").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_7" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_7"]){return false;} window["gf_submitting_7"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_7"]){return false;} window["gf_submitting_7"]=true; jQuery("#gform_7").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=7&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_7" value="1">
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<input type="hidden" class="gform_hidden" name="state_7" value="WyJbXSIsImY1YmUxZTUzZDk4MWRhOGRiYWZkZmFmYTUwMGU5MWEyIl0=">
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<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
</form>POST /diagnostic-solutions-order-form/
<form method="post" enctype="multipart/form-data" id="gform_6" class="btn-ghost gform_legacy_markup" action="/diagnostic-solutions-order-form/">
<div class="gform_body gform-body">
<ul id="gform_fields_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_6_1" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_6_1"><label class="gfield_label" for="input_6_1">Email<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_1" id="input_6_1" type="text" value="" class="large" tabindex="1" placeholder="Email Address *" aria-required="true" aria-invalid="false">
</div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_6" class="gform_button button" value="Submit" tabindex="2"
onclick="if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_6" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="6">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_6" value="WyJbXSIsImY1YmUxZTUzZDk4MWRhOGRiYWZkZmFmYTUwMGU5MWEyIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_6" id="gform_target_page_number_6" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_6" id="gform_source_page_number_6" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>Text Content
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info@commdx.com888-258-5966Provider PortalBill Pay888-258-5966
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Commonwealth Diagnostics International
Your Trusted Partner for Functional GI Diagnostics
* Diagnostic Solutions
* SIBO & IMO
* Fructose Malabsorption
* Lactose Malabsorption
* Sucrose Malabsorption
* IBSchek®
* MyGiHealth
* Who We Serve
* Clinical Trials
* Resources
* News & Insights
* Publications | Guides | eBooks
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ORDER NOW
info@commdx.comProvider PortalBill PayFor ProvidersFor PatientsFeedbackORDER NOW
* Diagnostic Solutions
* SIBO & IMO
* Fructose Malabsorption
* Lactose Malabsorption
* Sucrose Malabsorption
* IBSchek®
* MyGiHealth
* Who We Serve
* Clinical Trials
* Resources
* News & Insights
* Publications | Guides | eBooks
* Clinical & Industry Resources
* Provider Resource Center
* Patient Resource Center
* COVID-19 Response
* About
* Company Overview
* Laboratory, Technology & Science
* Leadership & Advisory Team
* Insurance & Billing Policies
* Contact Us
info@commdx.com888-258-5966Provider PortalBill PayFor ProvidersFor
PatientsFeedback
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ORDER NOW
DIAGNOSTIC SOLUTIONS ORDER FORM
NEW: ONE SIMPLE DIAGNOSTIC SOLUTIONS ORDER FORM FOR ALL YOUR FUNCTIONAL GI
DIAGNOSTIC SOLUTIONS
COMPLETE THE ONLINE FORM TO ORDER A BREATH TEST OR IBSCHEK
NO ACCOUNT SETUP NEEDED
MULTIPLE BILLING & SHIPPING OPTIONS AVAILABLE
DEDICATED CUSTOMER SERVICE AND PATIENT OUTREACH
Provider Order Form (PDF)
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DIAGNOSTIC TEST ORDER FORM
* STEP 1: GET STARTED
* Get Started:*
* Healthcare Provider: Ship to Practice
* Healthcare Provider: Ship to Patient
* Patient (IBSchek Self-Pay Only)
* I understand that I am responsible to pay for IBSchek prior to the order
being processed and shipped.*
* I agree to pay the $99 test fee and would like to speak to customer
service about processing my order.
* I would like to speak to customer service about the payment plan options
and financial hardship programs offered by CDI.
NOTE: IBSchek is not available for residents of New York.
* STEP 2 OF 4: PROVIDER & PRACTICE INFO
* Provider Name*
First Last
* Provider NPI#*
* Provider Signature*
*By signing this order form, the ordering practice represents that it has the
appropriate prescribing rights to order the tests selected on this form.
Reset to re-sign.
* Practice Address*
Street Address Address Line 2 City AlabamaAlaskaAmerican
SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern
Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth
CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin
IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces
AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
* Practice Name*
* Practice Email*
* Practice Phone*
* Practice Fax
* Please send results via*
* Fax
* Email
* Web Portal
* STEP 3 OF 3: DIAGNOSTIC SOLUTIONS (SHIP TO PRACTICE)
* Sample Collection Kits*
* SIBO 10 Tube Lactulose
* SIBO 10 Tube Glucose
* SIBO 6 Tube Lactulose (pediatric use)
* Lactose 6 Tube
* Fructose 6 Tube
* Sucrose 6 Tube
NOTE: Only breath tests can be ordered as bulk shipments to practices. If you
are interested in ordering multiple IBSchek kits to distribute from your
office, please contact the CDI provider services team.
* How many SIBO 10 Tube Lactulose kits?*
1 of 2 max characters
* How many SIBO 10 Tube Glucose kits?*
1 of 2 max characters
* How many SIBO 6 Tube Lactulose (pediatric use) kits?*
1 of 2 max characters
* How many Sucrose 6 Tube kits?*
1 of 2 max characters
* How many Lactose 6 Tube kits?*
1 of 2 max characters
* How many Fructose 6 Tube kits?*
1 of 2 max characters
* STEP 3 OF 4: DIAGNOSTIC SOLUTIONS (SHIP TO PATIENT)
* Sample Collection Kits*
* SIBO 10 Tube Lactulose
* SIBO 10 Tube Glucose
* SIBO 6 Tube Lactulose (pediatric use)
* IBSchek Capillary Collection Kit
* Lactose 6 Tube
* Fructose 6 Tube
* Sucrose 6 Tube
NOTE: IBSchek cannot be ordered by practices located in New York.
* Multiple Kits?
* My patient needs 2 of the same type of kit for pre and post treatment.
* For which kit(s)?*
* STEP 4 OF 4: PATIENT INFO
* Patient Name*
First Last
* Patient Date of Birth*
Month123456789101112
Day12345678910111213141516171819202122232425262728293031
Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
* Patient Shipping Address*
Street Address Address Line 2 City AlabamaAlaskaAmerican
SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern
Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth
CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin
IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces
AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
* Patient Email
Entering a patient email address is highly encouraged as it allows CDI to
provide direct patient outreach and support during the test-taking process.
* Patient Email*
* Patient Phone
* ICD-10 Code for Breath Tests*
* These codes are listed as a convenience. Ordering practitioners should
report the diagnosis code(s) that best describe the reason for performing the
test, regardless of whether the code is listed above or not.
* R10.84 Generalized abdominal pain
* R14.0 Abdominal distension (gaseous)
* R19.7 Diarrhea, unspecified
* K59.0 Constipation
* K58.0 Irritable Bowel Syndrome with diarrhea
* A04.9 Bacterial intestinal infection, unspecified
* Other(s):
* Additional ICD-10 Codes for Breath Tests*
* ICD-10 Code for IBSchek*
* These codes are listed as a convenience. Ordering practitioners should
report the diagnosis code(s) that best describe the reason for performing the
test, regardless of whether the code is listed above or not.
* K58.0 Irritable Bowel Syndrome with diarrhea
* Other(s):
* Additional ICD-10 Codes for IBSchek*
* STEP 2 OF 4: PATIENT INFO
* Patient Name*
First Last
* Patient Date of Birth*
Month123456789101112
Day12345678910111213141516171819202122232425262728293031
Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
* Patient Shipping Address*
Street Address Address Line 2 City AlabamaAlaskaAmerican
SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern
Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth
CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin
IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces
AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
* Patient Email
Entering a patient email address is highly encouraged as it allows CDI to
provide direct patient outreach and support during the test-taking process.
* Patient Email*
* Patient Phone
* STEP 3 OF 4: IBSCHEK PATIENT QUESTIONNAIRE
* Would you like to find out if you have certain types of Irritable Bowel
Syndrome by taking a test?*
* Yes
* No
* Have you ever been tested for IBS-D or IBS-M?*
* Yes
* No
* Have you had any of the following in the PAST 3 MONTHS?*
(Check all that apply)
* Abdominal pain or discomfort
* Diarrhea
* Constipation
* Constipation alternating with diarrhea
* Gas
* Abdominal bloating
* Belly pains or cramps, usually in the lower half of the belly, that get
worse after meals and feel better after a bowel movement
* Change in bowel movement frequency (more than three bowel movements per
day, diarrhea or loose stool, or less than three bowel movements per week)
* Change in appearance of stool: hard pellets, not well formed, undigested
food, liquid, mucus
* Harder or looser stools than normal (pellets or flat ribbon stools)
* Digestive issues beginning after an episode of gastroenteritis more
commonly known as food poisoning
* None of the above
* Have you had any of the following in the PAST 12 MONTHS*
(Check all that apply)
* Abdominal pain or discomfort
* Diarrhea
* Constipation
* Constipation alternating with diarrhea
* Gas
* Abdominal bloating
* Belly pains or cramps, usually in the lower half of the belly, that get
worse after meals and feel better after a bowel movement
* Change in bowel movement frequency (more than three bowel movements per
day, diarrhea or loose stool, or less than three bowel movements per week)
* Change in appearance of stool: hard pellets, not well formed, undigested
food, liquid, mucus
* Harder or looser stools than normal (pellets or flat ribbon stools)
* Digestive issues beginning after an episode of gastroenteritis more
commonly known as food poisoning
* None of the above
* Have you ever been diagnosed with:*
(Check all that apply)
* Celiac Disease
* Clodstridium Difficile
* Crohn's Disease
* Dyspepsia
* Dysphagia
* Food allergies
* Gastroparesis
* Inflammatory Bowel Disease (IBD)
* Irritable Bowel Syndrome (IBS)
* Lactose intolerance
* Malabsorption
* Small Intestinal Bacterial Overgrowth
* None of the above
* When was your last doctors appointment?*
* 0 - 1 month
* 2 - 3 months
* 3 - 6 months
* 6+ months
* None of the above
* STEP 4 OF 4: SELF-PAY BILLING INFO
* Thank you for your interest in IBSchek. Please review and submit your order
request. Our customer service team will be in contact with you shortly to
process this order.
* CDI offers convenient payment plans and financial hardship programs for
qualifying patients. The maximum out-of-pocket cost for IBSchek is $99 for
patients that pay promptly in accordance with CDI patient billing policies
and programs. Please submit your order and our customer service team will
reach out to discuss payment options.
* REVIEW & SUBMIT ORDER
* {all_fields:nohidden}
*
*
IMPORTANT INSURANCE & PAYMENT INFORMATION
CDI will submit a claim on the patient’s behalf to commercial insurance,
Medicare or Tricare. Insurance may cover some or all of the test depending on
the patient’s insurance plan and benefits. In the event the patient’s insurance
provider denies the insurance claim, or if the patient has not met the
deductible or has a coinsurance or co-pay, or if for any reason the insurance
does not cover the full amount of the test, the patient is responsible to pay
CDI for products and services received.
CDI does not accept any Medicaid plans: therefore any Medicaid patient taking a
test will be responsible for the full cost of the test. CDI offers convenient
payment plans and financial hardship programs for qualifying patients. Patients
may pay upfront via check sent with the kit or credit card. The maximum
out-of-pocket cost is $199 per breath test and $99 per IBSchek for patients that
pay promptly in accordance with CDI patient billing policies and programs. Click
here for an updated list of in-network providers.
PROVIDER RESOURCES
Access diagnostic instructions, test interpretation support, patient resources,
practice FAQs and more.
Provider Resources
Provider Portal
PATIENT RESOURCES
Access instructional videos, test FAQs, billing information, and more.
Patient Resources
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info@commdx.com
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(888) 258-5966
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