Requisition Forms


Clinicians can use our requisition form to order our breath tests for their patients. AerodiagnosticsTM test requisitions can be customized to simplify and streamline the ordering process. There is no need to stock breath collection kits in your office. AerodiagnosticsTM delivers breath collection kits directly to your patient to eliminate your staff time associated with the breath collection instruction and questions from your patients with regard to the breath specimen preparation and collection.

Most importantly, by delivering breath collection kits directly to your patients AerodiagnosticsTM is able to reduce variability in the hydrogen and methane breath test, ultimately delivering a highly accurate result. A customized AerodiagnosticsTM test requisition only requires a clinician signature, date, ICD 10 Code(s) (if third party commercial insurance is being used for payment - NO Medicare, Medicaid, Tricare, or Supplemental programs). AerodiagnosticsTM will also require patient demographic information to ensure prompt delivery of the breath collection kit.

Clinicians and/or their staff can fill in the patient section of the AerodiagnosticsTM test requisition, or simply attach a patient face sheet/demographic sheet. The completed requisition can be emailed to customerservice@aerodiagnostics.com or faxed to 1.617.860.6617. AerodiagnosticsTM will confirm each order via email and ship a breath collection kit directly to your patient via FedEx 2 Day delivery.

AerodiagnosticsTM tracks each shipment and contacts your patient to offer assistance with preparation, collection of breath specimens, return shipping, and payment questions. AerodiagnosticsTM processes patient specimens within 24 business hours and delivers an encrypted email link to our portal for access to your patient's final report. AerodiagnosticsTM personnel are available to review results and answer any questions with clinicians.

United States

Please use this form if you are a provider in the US.


AerodiagnosticsTM Sample Report


Sample Report

Test Instructions


Clinicians can download the test instructions.

AerodiagnosticsTM is happy to answer any questions you may have.

We are available Monday - Friday from 9am EST to 6pm EST at 1.617.608.3832

SIBO - Lactulose


SIBO - Glucose


Lactose Intolerance


Sucrose Intolerance


Fructose Intolerance


Frequently Asked Questions


  • Orders may be placed via the AerodiagnosticsTM Online Store (24 hours a day), by telephone (1.617.608.3832, Monday - Friday 9am- 6pm EST), or via fax at 1.617.860.6617.
  • Orders received after 2 pm EST are not eligible for same day shipping and will be processed the following business day.
  • Payment forms accepted: Check, money order, credit card. Pricing is subject to change without notification. AerodiagnosticsTM does not offer price matching since our products and services are unique.
  • Once an order is placed, no further changes can be made unless the order has not been shipped to you already.
  • To cancel an order prior to your breath collection kit being shipped, please contact us at 1.617.608.3832.
  • No fees will be charged to a patient who received an AerodiagnosticsTM Sucrose Intolerance Breath Collection Kit as part of the QOL Medical Complimentary Sucrose Intolerance Test Program.
  • Orders placed before 2 pm EST for Home Breath Collection Kits are typically processed within one (1) business day from date of order.
  • Clinicians can order AerodiagnosticsTM Breath Collection Kits for their patients by contacting AerodiagnosticsTM via email, online ordering, or calling us at 1.617.608.3832.
  • Patients can obtain AerodiagnosticsTM Breath Tests through their clinician or by ordering directly online. Breath collection kits will be shipped directly to your home. Small Intestinal Bacterial Overgrowth with Lactulose can only be ordered by a licensed medical professional.
  • AerodiagnosticsTM offers five different hydrogen and methane breath tests for gastrointestinal disorders (Sucrose, Lactose, Fructose Intolerances/malabsorptions & Small Intestinal Bacterial Overgrowth with Lactulose or Glucose).
  • To ensure accuracy of the results it is not possible to collect breath specimens for more than one breath test on the same day.
  • The highly specific nature of the technology requires a 24 hour preparation. The first 12 hours you will follow a limited diet and you will fast for the second 12 hours prior to collecting your breath specimens.
  • The patient or clinician will place the labeled test tubes containing your breath test specimens into the bubble wrap bags (located in the breath collection kit).
  • The bubble wrap bags containing your breath specimens should then be carefully placed back into the breath collection box you received.
  • Please apply your shipping label to the outside of the shipping box and return to AerodiagnosticsTM at:

  • AerodiagnosticsTM
  • One Cranberry Hill
  • Suite 304
  • Lexington MA 02421
  • All items returned to AerodiagnosticsTM are subject to a 20% restocking fee. If the return is due to an error on behalf of AerodiagnosticsTM the restock fee will be waived. Any item that is not in its original condition, damaged, have missing parts (including the unused shipping return label) will be subject to a $59.95 return fee. This may also result in an invoice to you for any additional shipping costs incurred by AerodiagnosticsTM for the shipping/receipt of the returned product. Outbound/Inbound shipping charges will result in an invoice to you unless the error is due to AerodiagnosticsTM. Individuals who do not return AerodiagnosticsTM breath collection kits to the AerodiagnosticsTM Laboratory at One Cranberry Hill, Suite 304, Lexington, MA 02421 within 60 days of receipt will be responsible for a $59.95 return fee.
  • No fees will be charged to a patient who received an AerodiagnosticsTM Sucrose Intolerance Breath Collection Kit as part of the QOL Medical Complimentary Sucrose Intolerance Test Program.
  • Patient specimens are immediately processed upon receipt in our laboratory.
  • Breath test results will be made available to the ordering clinician or the patient (if ordered directly) within one (1) business day following completion of testing.
  • Patients can contact their clinician directly to schedule a follow up appointment to discuss their Breath Test results.
  • It is important that patients and clinicians contact AerodiagnosticsTM Customer Service (1.617.608.3832) with any questions prior to, during, or following any breath collection. AerodiagnosticsTM is open Monday through Friday from 9:00am to 6:00pm EST.
  • Please visit our "Contact Us" section or email us at customerservice@aerodiagnostics.com to send us a message if you would like a response during non-business hours.
  • If your intention is to submit for reimbursement from your insurance provider, please be advised that insurance providers may reject your claim for reimbursement. This can be due to multiple reasons, not limited to just the following conditions:
  • AerodiagnosticsTM LLC who is analyzing trace gas values in the breath sample provided and is not providing medical advice.
  • Purchasing the tests from an online store does not constitute medical advice from a licensed practitioner.
  • AerodiagnosticsTM LLC or its employees are not involved with all insurance carriers and does not insist that consumers attempt to submit their test for insurance reimbursement.
  • We provide the tests at reasonable prices to accommodate consumers paying out-of-pocket. If you prefer to have your insurance cover the test, it is advised you speak with your insurance provider in advance of any purchase.
  • The majority of health care insurance providers will cover all or a portion of the cost of an AerodiagnosticsTM Breath Test. Patients should contact their insurance provider in advance of the test to fully understand their responsibility for any deductible charge, coinsurance, or co-pay that may be required by their insurance carrier as a result of their plan.
  • A health insurance pre-authorization may or may not be required depending on your specific health insurance carrier and chosen health plan. Health plan insurance products vary as to their requirements regarding pre-authorization. AerodiagnosticsTM recommends that you contact your health insurance organization to learn about any pre-authorization requirements prior to taking a breath test. Many health plans have in and out of network requirements that you should be aware of prior to taking a breath test. If your heath plan provides you with a pre-authorization number, please ensure that number is placed on the AerodiagnosticsTM Requisition along with all pertinent patient and health plan information. Complete and accurate patient and health plan information is the best way to ensure you maximize your allowable benefits under your plan and reduce any unnecessary out of pocket expenses.
  • A patient with no health insurance may still be able to access AerodiagnosticsTM services. We ask patients without insurance to contact our office directly at 1.617.608.3832 to review all available options. At AerodiagnosticsTM we are committed to serving patients suffering from gastrointestinal disorders and will do everything possible to work with them and their clinician to provide the critical information needed to assist their clinician with an appropriate diagnosis.

Contact Us


Contact Info

One Cranberry Hill, Suite 304,
Lexington, Massachusetts 02421

customerservice@aerodiagnostics.com

1.617.608.3832

1.844.681.9449

1.617.860.6617

Questions, Information or to make an appointment

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