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Requisition / Billing Details

First and last name must match your government-issued ID exactly. Include all given names in the first name field (e.g. "Maria Elena" not just "Maria"). This information is used on your lab requisition.

First name *

Last name *

Email address *

Your account will be created with this email if you don't have one.

Phone *

Required for your Dynacare requisition.

Street address *

Apartment, suite, unit, etc.

City *

Province *

Ontario only.

Postal code *

Country

Requested Tests

Help us understand why you're requesting these tests so we can review your order appropriately.

Please explain why you are requesting these tests *

Health Profile

This information is reviewed alongside your test request. It is not stored as a persistent profile.

Gender / Chromosome *

Male XY Female XX

Date of Birth *

Past and Current Medical Conditions *

Current Medications *

Current Supplement Regimen *

Daily Diet Composition *

Liability / Indemnification / Phlebotomy

Please read and acknowledge each statement below.

I acknowledge that I am not under the care of Bespoke Labs or Dr. Syed Asghar Abbass, and that no doctor-patient relationship is created by placing this order.

I acknowledge that no diagnosis will be made based on the results of these tests, and that Bespoke Labs does not provide medical advice or interpretation.

I acknowledge that if any results are flagged as critical, I will be notified by email and it is my responsibility to seek immediate medical attention.

Payment

Your card will be authorized but not charged until your order is reviewed and approved.

Leave this empty

Order Summary

Subtotal $0.00

Bespoke fee $0.00

Dynacare fee $0.00

HST (13%) $0.00

Total $0.00

Your card will be authorized, not charged, until we review your order.

Order Placed

Your card has been authorized and your order is under review.

Please note that we process requests Monday through Friday from 6:00 a.m. to 4:30 p.m. Eastern Time.

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