REQUEST SAMPLE COLLECTION KITS

TEST INCLUDES GENES POTENTIALLY ASSOCIATED WITH SEVERAL RARE GENETIC DISORDERS OF OBESITY

Please complete the form below to request kits for in-office sample collection (blood or buccal swab).

*Denotes required field

First Name* First Name is a required field.

Last Name* Last Name is a required field.

NPI Number* NPI Number is a required field.

Specialty is a required field. Please enter 50 characters max.

Designation is a required field. Please enter 50 characters max.

Email Address* Please enter a valid email address!

Practice Phone* [ex: (123) 123-1234]

Practice Name

Street Address* Street Address is a required field.

Street Address 2

City* City is a required field.

State is a required field.

Zip Code* [ex: 55555] Zip Code must be at least 5 characters!

Preferred Return Shipping Method is a required field.

Type of Sample Collection Kit is a required field.

# of Kits is a required field.

*By submitting my information, I certify that I am a healthcare professional licensed in the United States and agree to receive program communications and materials, disease education and product-related information from Rhythm Pharmaceuticals ("Rhythm") and companies working with Rhythm, in connection with the Uncovering Rare Obesity Program. By submitting this form, I also agree to Rhythm's Terms of Use. For further information regarding Rhythm's privacy practices, please refer to our Privacy Policy.

You must accept the terms and conditions before sending your message.

For questions about the program or to request sample collection kits by phone, please contact PreventionGenetics at 844-513-3994, Monday - Friday from 9am - 8pm ET.

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