Great Plains Laboratory Order Form Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * GPL Test Selection * Every test is eligible for the multi-test discount. For 2 tests placed on the same order, a 10% discount will be applied to the total cost of both tests; for 3 tests, a 15% discount will be applied; and for 4 tests or more, a 20% discount. (Select Test) MycoTOX Profile (Urine) $310 GPL- TOX Profile (Urine) $235 Organic Acids Test (Urine) $330 Microbial Organic Acids Test (Urine) $240 Glyphosate Test (Urine) $115 Glyphosate Test (Water) $115 Omega-3 Index Complete (Blood) $155 Calcium + Magnesium Profile (Urine) $215 Kryptopyrrole Test (Urine) $195 Vitamin D Test (Serum or Blood) $70 Comprehensive Stool Analysis with Parasitology $370 Microbiology Test $205 Additional Tests For any additional tests needed, fill in test name below: Thank you!