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). 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 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.

Requisition Form

Please use this form if you are a provider in the US.
It is a writeable PDF, so you can edit it directly on your computer and then email it to

Free Sucrose Intolerance Test

Please use this form for a complimentary Sucrose Intolerance Test.

AerodiagnosticsTM Sample Report

Sample Report

Instructions on Collecting Your Breath Specimens

SIBO - Lactulose

SIBO - Glucose

Lactose Intolerance

Sucrose Intolerance

Fructose Intolerance