Important Next Step to Receive your Wyndly At-Home Allergy Test
Welcome to Wyndly! We need to collect essential patient information before we can ship your at-home allergy test and create a personalized treatment plan to fix your allergies.
Patient and Contact Information
The patient is the person who will be taking the allergy test. The contact is who Wyndly should reach out to for scheduling and billing. For most people, this is the same person. For parents and minor children, the parent is the contact and the child is the patient. The patient must be present during the doctor consultation.
Patient Full Name
*
First Name
Last Name
How did you hear about Wyndly?
Referral by my doctor
Friend/Family
Google
Facebook/Instagram
Video (TikTok/YouTube)
Patient Date of Birth
*
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Month
-
Day
Year
Patient Gender
*
Email (who should we contact for scheduling the follow-up?)
*
IMPORTANT: Please provide the same email as your order so we can match you on our patient records.
Phone Number
*
Format: (000) 000-0000.
Address (where should we mail your test kit?)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What symptoms does the patient experience? (pick all that apply)
*
stuffy nose
watery eyes
scratchy throat
runny nose
sneezing
post-nasal drip
Other
Have you tried allergy medications and still have frustrating symptoms?
*
Yes
No
What medications has the patient tried for allergies? (pick all the apply)
*
Over-the-counter or prescription antihistamines (Benadryl, Claritin, Zyrtec, etc)
Nasal treatments (Flonase, Nasonex, Afrin, saline rinses, etc)
Allergy Eye Drops
Allergy Shots
Other
Insurance
Wyndly does not bill your insurance. Our partner lab bills your health insurance.When uploading health insurance information, make sure it is easily readable and well-lit. Your insurance may deny your claim otherwise.
We want to avoid surprise bills! Due to regulations, our partner lab cannot bill insurance if you have Medicaid, Medicare, Tricare, or Kaiser.
*
I have commercial insurance
I use a non-covered insurance plan (Medicaid, Medicare, Tricare, or Kaiser) and will email care@wyndly.com for a refund
Please upload or take a photo of the front of your health insurance card. Wyndly will not bill your insurance, but Spiriplex (the lab) will bill the lab processing costs of your test to your health insurance. Please ensure all photos are well-lit and clear (otherwise your insurance may deny your claim).
Please upload or take a photo of the back of your health insurance card. Wyndly will not bill your insurance, but Spiriplex (the lab) will bill the lab processing costs of your test to your health insurance. Please ensure all photos are well-lit and clear (otherwise your insurance may deny your claim).
Front of Health Insurance Card (Well-lit and Clear)
*
Back of Health Insurance Card (Well-lit and Clear)
*
You consent to have your blood allergy testing billed by the lab to your health insurance. While most insurances cover allergy testing, not all do. Every policy is different. As a safeguard, Wyndly has negotiated that your patient responsibility for out-of-pocket cost for blood testing if it is not covered by insurance through Spiriplex is at most $250, even if your insurance denies coverage.
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Today's date
*
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Month
-
Day
Year
Shopify Order Id
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