Lactulose Breath Testing Orders For Lactulose Breath Testing orders, please complete the form below PROVIDER DETAILS Referring Provider * First Name Last Name Clinic Name * Phone * (###) ### #### Fax * (###) ### #### ICD.10 Code(s) * REQUESTED TESTING * Eleven sample 3 hour lactulose breath test for hydrogen and methane kit - $215 Two Sample "Spot" baseline methane (no substrate challenge) kit - $60 Heidelberg Test - $350 PATIENT DETAILS Patient Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### PAYMENT DETAILS Name on Credit Card * First Name Last Name Credit Card Number * Expiration Date * CVV * Zip Code Credit Card is Mailed To * Thank you!
