Sjögren Syndrome

Sjögren Syndrome Lab Tests and health information

The Sjögren Syndrome test looks for the presence of antibodies common in Sjögren's syndrome. The results of an ANA (antinuclear antibody) test will help determine if you have an autoimmune disorder. 

Are you wondering what kind of Sjögren syndrome test is available? Learn more about the types of Sjögren syndrome testing available and order directly from Ulta Lab Tests to know about your health today!

Below the list of tests is a guide that explains and answers your questions on what you need to know about Sjögren syndrome tests, along with information on Sjögren syndrome, signs, symptoms, and diagnosis.


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Sjögren's Syndrome Diagnostic Panel, Comprehensive

IMPORTANT:  RELEX Testing by Quest is included in this panel. Quest will execute the tests automatically if any of the following is triggered, and there will be an extra charge for each test that Quest runs. 

By ordering this test panel, you agree to pay extra for Quest's reflex tests.
  • If ANA Screen, IFA is positive, then ANA Titer and Pattern will be performed at an additional charge (CPT code(s): 86039).
  • If Mitochondrial Antibody Screen is positive, then Mitochondrial Antibody Titer will be performed at an additional charge (CPT code(s): 86381).

Sjögren's antibodies (SS-B) is detected in approximately 15% of patients with Sjögren's Syndrome. Sjögren's antibody (SS-B) is present only if Sjögren's antibody (SS-A) is also detected. The presence of both antibodies (SS-A and SS-B) strengthen the diagnosis of Sjögren's Syndrome and conveys prognostic information.

Sjögren's Antibodies (SS-B) is detected in approximately 15% of patients with Sjögren's Syndrome. Sjögren's Antibody (SS-B) is present only if Sjögren's Antibody (SS-A) is also detected. The presence of both antibodies (SS-A and SS-B) strengthen the diagnosis of Sjögren's Syndrome and conveys prognostic information.

Sjögren's Antibody (SS-B) is detected in approximately 15% of patients with Sjögren's Syndrome. Sjögren's Antibody (SS-B) is present only if Sjögren's Antibody (SS-A) is also detected. The presence of both antibodies (SS-A and SS-B) strengthen the diagnosis of Sjögren's Syndrome and conveys prognostic information.

Early Sjogren's Syndrome Profile

Includes

Carbonic Anhydrase VI (CA VI) IgG Antibodies, Carbonic Anhydrase VI (CA VI) IgA Antibodies, Carbonic Anhydrase VI (CA VI) IgM Antibodies
Parotid Specific Protein (PSP) IgG Antibodies, Parotid Specific Protein (PSP) IgA Antibodies, Parotid Specific Protein (PSP) IgM Antibodies
Salivary Protein 1 (SP-1) IgG Antibodies, Salivary Protein 1 (SP-1) IgA Antibodies, Salivary Protein 1 (SP-1) IgM Antibodies

 

Clinical Significance

Sjogren's syndrome (SS) is a systemic autoimmune disease in which loss of salivary gland and lachrymal gland function is associated with hypergammaglobulinemia, autoantibody production, mild kidney and lung disease and eventually lymphoma. SS involves dry eyes and dry mouth without systemic features that may be either primary or secondary to another autoimmune disease, such as SLE. Patients with SS and picked up at a late stage in their disease, after the salivary glands and lachrymal glands are already destroyed, because they are asymptomatic until that time. At this point, only symptomatic treatment can be offered for abnormal lachrymal and salivary gland function. The diagnosis for SS is currently at a crossroad with the American College of Rheumatology providing which requires characteristic autoantibodies (SS-A/SS-B) or minor salivary gland biopsy. Since lip biopsies are not frequently performed in clinical practice, there is increased emphasis placed on autoantibodies in diagnosis. The current Ro and La antibodies can delay the diagnosis by over 6 years.Recently novel antibodies identified to salivary gland protein 1 (SP-1), carbonic anhydrase 6 (CA6) and parotid secretory protein (PSP) using western blot methodology. Further studies have shown that the isotype differentiation of the markers adds to the sensitivity of diagnosis of SS. These autoantibodies occurred earlier in the course of the disease than antibodies to Ro or La. In addition antibodies to SP-1, CA-6 and PSP were found in patients meeting the criteria for SS who lacked antibodies to Ro or La. Furthermore, in patients with idiopathic xerostomia and xerophthalmia for less than 2 years, 76% had antibodies to SP-1 and/or CA6 while only 31% had antibodies to Ro or La.
Antibodies to different isotypes (IgG, IgM & IgA of SP-1, CA6 and PSP are useful markers for identifying patients with SS at early stages of the disease or those that lack antibodies to either Ro or La.


Antinuclear antibodies are associated with rheumatic diseases including Systemic Lupus Erythematous (SLE), mixed connective tissue disease, Sjogren's syndrome, scleroderma, polymyositis, CREST syndrome, and neurologic SLE. 

Reflex Information: If ANA Screen, IFA is positive, then ANA Titer and Pattern will be performed at an additional charge.


Includes

  • ANA Screen,IFA, with Reflex to Titer and Pattern
  • DNA (ds) Antibodies
  • Scleroderma Antibodies (SCL-70)
  • Sm and Sm/RNP Antibodies
  • Sjogren's Antibodies (SSA, SSB)

If ANA Screen, IFA is positive, then ANA Titer and Pattern will be performed at an additional charge - $13.00

 


ANAlyzeR™ ANA, IFA with Reflex Titer/Pattern, Systemic Autoimmune Panel 1

Includes

  • ANA Screen,IFA, with Reflex to Titer and Pattern
  • DNA (ds) Antibody, Crithidia IFA with Reflex to Titer
  • Chromatin (Nucleosomal) Antibody
  • Sm Antibody
  • Sm/RNP Antibody
  • RNP Antibody
  • Sjogren's Antibodies (SS-A, SS-B)
  • Scleroderma Antibody (Scl-70)
  • Jo-1 Antibody
  • Centromere B Antibody
  • Complement Component C3c and C4c
  • Cardiolipin Antibodies (IgA, IgG, IgM)
  • Beta-2-Glycoprotein I Antibodies (IgG, IgA, IgM)
  • Rheumatoid Factor (IgA, IgG, IgM)
  • Cyclic Citrullinated Peptide (CCP) Antibody (IgG)
  • 14.3.3 eta Protein
  • Thyroid Peroxidase Antibodies (TPO)

 

  • If ANA Screen, IFA is positive, then ANA Titer and Pattern will be performed at an additional charge (CPT code(s): 86039).
  • If the DNA (ds) Antibody Screen is positive, then DNA (ds) Antibody Titer will be performed at an additional charge (CPT code(s): 86256).

 

Alternative Name(s)

Expanded ANA Antibodies,Systemic Autoimmune Disorder,ANA and Expanded AI Testing,ANA and Systemic Autoimmunity,Comprehensive AI Testing,Early Systemic Autoimmune Disease,Autoimmune Disorders


Clinical Significance

Rheumatoid Arthritis Diagnostic IdentRA® Panel 2 - Early diagnosis of rheumatoid arthritis (RA), ie, diagnosis before significant joint erosion occurs, is difficult. Psoriatic arthritis can also be difficult to diagnose clinically early in the disease process, and there are no specific biomarkers. The 14-3-3η (eta) protein is an emerging biomarker for RA and erosive psoriatic arthritis diagnosis. It may play a biologic role in the joint erosive process. Blood levels appear to be elevated in patients with RA, but not in other diseases including psoriasis, osteoporosis, gout, ulcerative colitis, type 1 diabetes, systemic lupus erythematosus, Crohn disease, primary Sjögren syndrome, scleroderma, and multiple sclerosis. The 14-3-3η protein, used in conjunction with rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) antibody, may improve diagnostic sensitivity in the early diagnosis of RA. It may also help differentiate those with psoriatic arthritis joint damage from those without joint damage.


Rheumatoid Factor (IgA, IgG, IgM) 

Reference Range(s)

  • Rhematoid Factor (IgA)
    • ≤6 Negative
    • >6 Positive
  • Rhematoid Factor (IgG)
    • ≤6 Negative
    • >6 Positive
  • Rhematoid Factor (IgM)
    • ≤6 Negative
    • >6 Positive

Rheumatoid factor is commonly used as a blood test for the diagnosis of rheumatoid arthritis. However, rheumatoid factor can also be present in individuals with other conditions such as lupus, infectious hepatitis, syphilis, mononucleosis, tuberculosis, liver disease, and sarcoidosis. Rheumatoid factor is an antibody that is detectable in the blood of 80% of adults with rheumatoid arthritis. Rheumatoid can be detected in the blood of normal individuals and of those with other autoimmune diseases that are not rheumatoid arthritis. In people with rheumatoid arthritis, high levels of rheumatoid factor can indicate a tendency toward more aggressive disease and/or a tendency to develop rheumatoid nodules and rheumatoid lung disease. Rheumatoid factor is actually an antibody that can bind to other antibodies. Antibodies are normal proteins in our blood that are important parts of our immune system. Rheumatoid factor is an antibody that is not usually present in the normal individual. Rheumatoid factor is commonly used as a blood test for the diagnosis of rheumatoid arthritis. Rheumatoid factor is present in about 80% of adults (but a much lower proportion of children) with rheumatoid arthritis.

Rheumatoid factor is commonly used as a blood test for the diagnosis of rheumatoid arthritis. However, rheumatoid factor can also be present in individuals with other conditions such as lupus, infectious hepatitis, syphilis, mononucleosis, tuberculosis, liver disease, and sarcoidosis. Rheumatoid factor is an antibody that is detectable in the blood of 80% of adults with rheumatoid arthritis. Rheumatoid can be detected in the blood of normal individuals and of those with other autoimmune diseases that are not rheumatoid arthritis. In people with rheumatoid arthritis, high levels of rheumatoid factor can indicate a tendency toward more aggressive disease and/or a tendency to develop rheumatoid nodules and rheumatoid lung disease. Rheumatoid factor is actually an antibody that can bind to other antibodies. Antibodies are normal proteins in our blood that are important parts of our immune system. Rheumatoid factor is an antibody that is not usually present in the normal individual. Rheumatoid factor is commonly used as a blood test for the diagnosis of rheumatoid arthritis. Rheumatoid factor is present in about 80% of adults (but a much lower proportion of children) with rheumatoid arthritis.

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Elevated RF is found in collagen vascular diseases such as SLE, rheumatoid arthritis, scleroderma, Sjögren's Syndrome, and in other conditions such as leprosy, tuberculosis, syphilis, malignancy, thyroid disease and in a significant percentage of otherwise normal elderly patients.

dsDNA Antibody is detected in patients with active systemic lupus erythematosus (SLE) and approximately 20% of patients with Mixed Connective Tissue Disease.

In conjunction with clinical findings and other laboratory tests, the high avidity dsDNA FARRZYME can be used as an aid to the diagnosis of systematic lupus erythematosus (SLE)

Useful in differentiating inflammatory and neoplastic diseases and as an index of disease severity. CRP is also useful in monitoring inflammatory disease states.

Increased CRP levels are found in inflammatory conditions including: bacterial infection, rheumatic fever, active arthritis, myocardial infarction, malignancies and in the post-operative state. This test cannot detect the relatively small elevations of CRP that are associated with increased cardiovascular risk.


A Complete Blood Count (CBC) Panel is used as a screening test for various disease states including anemia, leukemia, and inflammatory processes.

A CBC blood test includes the following biomarkers: WBC, RBC, Hemoglobin, Hematocrit, MCV, MCH, MCHC, RDW, Platelet count, Neutrophils, Lymphs, Monocytes, Eos, Basos, Neutrophils (Absolute), Lymphs (Absolute), Monocytes(Absolute), Eos (Absolute), Basos (Absolute), Immature Granulocytes, Immature Grans (Abs)

NOTE: Only measurable biomarkers will be reported.

Reflex Parameters for Manual Slide Review
  Less than  Greater Than 
WBC  1.5 x 10^3  30.0 x 10^3 
Hemoglobin  7.0 g/dL  19.0 g/dL 
Hematocrit  None  75%
Platelet  100 x 10^3  800 x 10^3 
MCV  70 fL  115 fL 
MCH  22 pg  37 pg 
MCHC  29 g/dL  36.5 g/dL 
RBC  None  8.00 x 10^6 
RDW  None  21.5
Relative Neutrophil %  1% or ABNC <500  None 
Relative Lymphocyte %  1% 70%
Relative Monocyte %  None  25%
Eosinophil  None  35%
Basophil  None  3.50%
     
Platelet  <75 with no flags,
>100 and <130 with platelet clump flag present,
>1000 
Instrument Flags Variant lymphs, blasts,
immature neutrophils,  nRBC’s, abnormal platelets,
giant platelets, potential interference
     
The automated differential averages 6000+ cells. If none of the above parameters are met, the results are released without manual review.
CBC Reflex Pathway

Step 1 - The slide review is performed by qualified Laboratory staff and includes:

  • Confirmation of differential percentages
  • WBC and platelet estimates, when needed
  • Full review of RBC morphology
  • Comments for toxic changes, RBC inclusions, abnormal lymphs, and other
  • significant findings
  • If the differential percentages agree with the automated counts and no abnormal cells are seen, the automated differential is reported with appropriate comments

Step 2 - The slide review is performed by qualified Laboratory staff and includes: If any of the following are seen on the slide review, Laboratory staff will perform a manual differential:

  • Immature, abnormal, or toxic cells
  • nRBC’s
  • Disagreement with automated differential
  • Atypical/abnormal RBC morphology
  • Any RBC inclusions

Step 3 If any of the following are seen on the manual differential, a Pathologist will review the slide:

  • WBC<1,500 with abnormal cells noted
  • Blasts/immature cells, hairy cell lymphs, or megakaryocytes
  • New abnormal lymphocytes or monocytes
  • Variant or atypical lymphs >15%
  • Blood parasites
  • RBC morphology with 3+ spherocytes, RBC inclusions, suspect Hgb-C,
  • crystals, Pappenheimer bodies or bizarre morphology
  • nRBC’s

Comprehensive Metabolic Panel


Antibodies to Sm are highly specific for systemic lupus erythematosus (SLE) and when present are considered a marker antibody. However, these antibodies are found in only 20% of patients with SLE. RNP antibodies (also known as anti-u1 or ribonucleoprotein antibodies) are found in 45% of SLE patients but are also observed in numerous other disease states such as Sjögren's syndrome, scleroderma and polymyositis. Elevated levels of antibodies to RNP are seen in mixed connective tissue disease. In SLE, RNP antibodies have been associated with a relatively benign disease course with lower incidence of renal and central nervous system involvement. Patients may be considered positive for RNP antibodies when the RNP antibody result is significantly higher than the Sm antibody result.

Smith Antibody (Sm) is highly specific for systemic lupus erythematosus (SLE). Smith Antibody is also detected in approximately 15% of patients with SLE. Smith Antibody is detected in more than half of young African-American women with SLE.

Cardiolipin antibodies (CA) are seen in a subgroup of patients with autoimmune disorders, particularly Systemic Lupus Erythematosus (SLE), who are at risk for vascular thrombosis, thrombocytopenia, cerebral infarct and/or recurrent spontaneous abortion. Elevations of CA associated with increased risk have also been seen in idiopathic thrombocytopenic purpura, rheumatoid and psoriatic arthritis, and primary Sjögren's syndrome.

Cardiolipin antibodies (CA) are seen in a subgroup of patients with autoimmune disorders, particularly Systemic Lupus Erythematosus (SLE), who are at risk for vascular thrombosis, thrombocytopenia, cerebral infarct and/or recurrent spontaneous abortion. Elevations of CA associated with increased risk have also been seen in idiopathic thrombocytopenic purpura, rheumatoid and psoriatic arthritis, and primary Sjögren's syndrome.

Cardiolipin antibodies (CA) are seen in a subgroup of patients with autoimmune disorders, particularly Systemic Lupus Erythematosus (SLE), who are at risk for vascular thrombosis, thrombocytopenia, cerebral infarct and/or recurrent spontaneous abortion. Elevations of CA associated with increased risk have also been seen in idiopathic thrombocytopenic purpura, rheumatoid and psoriatic arthritis and primary Sjögren's syndrome.


Sjögren's syndrome is the third most common autoimmune disease. It lies behind rheumatoid arthritis and systemic lupus erythematosus in prevalence in the United States.

If you're diagnosed with Sjögren's syndrome, you may suffer from dry eye, dry mouth, and joint pain. This could lead to sight complications, gastrointestinal issues, heart problems, and more. On top of this, getting the diagnosis for a single autoimmune diagnosis puts you at a higher risk of developing other autoimmune diseases in the future.

So, you need to get a Sjögren's syndrome test if you're showing symptoms. The sooner you start receiving treatment, the better controlled your symptoms will be.

To learn more about Sjögren's syndrome, Sjögren's syndrome treatment, and Sjögren's syndrome tests for diagnosis, keep reading. We have everything you need to know.

What Is Sjögren's Syndrome?

Sjögren's syndrome is one of the many autoimmune diseases that scientists have recently discovered. This specific autoimmune disease targets the mucous membranes throughout the body. Since these moisture-producing glands are more prevalent around our eyes and mouth, the syndrome usually leads to chronic dry eye and dry mouth.

However, we should note that the syndrome is systemic. This means that it can cause complications all over your body. So, you may notice symptoms that affect muscles, joints, and even entire organ systems.

Since Sjögren's syndrome is an autoimmune disease, its presence can put patients at risk for the development of other autoimmune diseases. Mainly, patients with Sjögren's syndrome go onto develop rheumatoid arthritis and systemic lupus erythematosus.

Because of the discrepancy in autoimmune conditions, there are two kinds of Sjögren's syndrome: primary and secondary.

Primary Sjögren's syndrome refers to patients who have gland inflammation without an underlying rheumatologic condition. This means that the patient doesn't have any other conditions (including autoimmune diseases) that could cause muscle and/or joint pain.

Secondary Sjögren's syndrome refers to patients who have Sjögren's syndrome as well as another rheumatologic condition. There are three conditions that are common in secondary Sjögren's patients:

  1. Rheumatoid arthritis (RA)
  2. Systemic lupus erythematosus (SLE)
  3. Scleroderma

It's important to identify the kind of Sjögren's you have as well as the underlying condition you may have. This affects your treatment plan as well as your outcome.

What Are the Risk Factors for Sjögren's Syndrome?

The most important risk factor is your gender. Nine out of ten patients with Sjögren's syndrome are female. 

Next is age. Usually, patients who receive a Sjögren's diagnosis are in their forties or older. However, some researchers think that this is because it takes this long for symptoms to show in the patients.

Many rheumatologists use an early-show Sjögren's test in younger patients who are exhibiting mild symptoms. This can help physicians catch the condition much faster than they could before.

Lastly, we should emphasize (again) how the presence of one autoimmune disease can lead to the development of another. If a patient has an already-existing rheumatologic condition, they are more likely to develop Sjögren's syndrome.

This is why you may notice rheumatologists performing yearly panels on their patients. They are trying to make sure that they don't miss the development of one autoimmune disease while they're focusing on treating other conditions.

What Causes Sjögren's Syndrome?

Sjögren's syndrome is an autoimmune disease. This means that your immune system, which usually attacks foreign bacteria and viruses in your body, attacks your own body's cells and tissues instead.

As this happens, inflammation and pain develop. There is also damage done to the areas that your immune system is attacking. So, patients will live with residual symptoms their entire lives.

Physicians are not exactly sure what causes the syndrome, but they do suspect that there are genetic and environmental components to the development of the syndrome. Some researchers believe that some cases of Sjögren's may be tied to prior infections that set the immune system off course.

The discovery of autoimmune diseases is still relatively new. So, there are many studies that are still underway to find out more about the development of these diseases.

What Are the Signs and Symptoms of Sjögren's Syndrome?

As we mentioned before, there are two hallmark symptoms of Sjögren's syndrome: dry eyes and dry mouth. This is because the condition causes the immune system to attack the moisture-producing glands that lubricate the eyes and mouth.

Patients with dry eyes complain of an itchy, burning sensation in their eyes. Some patients use the word "gritty" to describe the sensation that they feel when they try to blink.

Patients with dry mouth complain of trouble speaking and swallowing. The dryness that develops in the mouths of Sjögren's patients comes from a lack of saliva. And, without that saliva, it can become difficult to use our mouth in ways that we're used to doing every day.

However, these aren't the only signs of the condition. Like most autoimmune diseases, Sjögren's is systemic. So, patients can experience symptoms all over the body.

Here are some of the most common symptoms that Sjögren's patients complain of:

  • Swollen salivary glands
  • Dental decay
  • Chronic dry cough
  • Dry skin
  • Skin rashes
  • Vaginal dryness
  • Fatigue
  • Joint pain
  • Muscle pain
  • Joint stiffness
  • Swelling in the joints

These symptoms can progress over time. And, in patients who have gone undiagnosed and/or untreated, the symptoms can progress even further.

Late-stage Sjögren's patients can develop burning and numbness in the extremities. And, the condition can lead to low red and white blood cell counts.

It's very important to diagnose and treat Sjögren's as soon as possible. The longer that the syndrome goes on without intervention, the worse the outcomes are for the patients.

What Are the Lab Tests to Diagnose Sjögren's Syndrome?

Unfortunately, there isn't a single test that can diagnose Sjögren's syndrome. Rheumatologists have to order a multitude of labs and tests. These are specific to Sjögren's and general to overall immune system health.

This is because there isn't a single antibody that is tied to Sjögren's syndrome. Rather, there are multiple antibodies and multiple inflammatory factors that are linked to the disease. These are things that your physician will try to find when they're searching for a diagnosis.

Here are some of the most common Sjögren's syndrome tests that rheumatologists use to diagnose the condition:

  • ANA screen - a general test that can signal the presence of autoimmune diseases.
  • Rheumatoid factor - tests for proteins that your immune system makes as it's attacking healthy tissue
  • Ds DNA antibody - normally specific for lupus but can be found in Sjögren's patients.
  • C-reactive protein - a general test for inflammation in the body.
  • Sedimentation rate - a general test that can sense high levels of inflammation in the body.
  • Comprehensive metabolic panel - a general test that can look at electrolyte levels in the body.
  • Complete blood count - a general test that can look for cells in the blood.
  • Protein electrophoresis - tests for the levels of immunoglobulins in the blood.
  • Ocular surface staining - the physician applies a stain to your eye, and this stain will conglomerate in places where there is erosion and/or damage to the eye from dryness.
  • Lip biopsy - the physician removes a sample of tissue from your salivary gland and looks at it under a microscope to determine whether or not there are signs of inflammation.
  • Sialometry - measures how much saliva that the glands produce during a set amount of time.

Our comprehensive Sjögren's syndrome panel tests for the following:

  • ANA Pattern
  • ANA Screen, IFA
  • Anti-Nuclear Ab Titer
  • Mitochondrial Ab Screen
  • Mitochondrial Ab Titer
  • Rheumatoid Factor
  • Sjögren's Antibody (Ss-A)
  • Sjögren's Antibody (Ss-B)
  • Thyroid Peroxidase

Physicians may also test for SS-A and SS-B antibodiesThe SS-B antibody is only present if the SS-A antibody is present. However, the presence of both the SS-A and SS-B antibodies can strengthen the diagnosis.

Some physicians may also perform a urinalysis to check for kidney damage.

Are There Any Diagnostic Tests for Sjögren's Syndrome?

Aside from laboratory tests, there are a few diagnostic tests that your physician may choose to run if they suspect that you have Sjögren's syndrome. Here are some of the most common diagnostic tests for Sjögren's syndrome:

  • Ultrasound - looks at the major salivary glands to check for abnormalities.
  • Neurological testing - a wide variety of neurological tests (biopsies of nerves, nerve conduction testing, MRIs, lumbar punctures, etc.) can determine whether or not Sjögren's could be causing nerve issues.

As your rheumatologist gathers more and more information about your condition, he/she will be able to figure out how serious it has gotten. If these tests come back negative, your rheumatologist may start testing for other conditions that cause the same or similar symptoms.

As with any symptoms and conditions, it's important to see a doctor as soon as possible for testing. If Sjögren's goes untreated for too long, it could cause permanent damage.

Getting Your Sjögren's Syndrome Test

If you believe that you could have Sjögren's syndrome, you need to get tested for Sjögren's syndrome. The results from tests offered by Ulta Lab Tests can help you determine - once and for all - whether these symptoms are from Sjögren's syndrome or if you should be considering other conditions.

If you get your tests for Sjögren's syndrome with Ulta Lab Tests, you're going to receive secure, confidential results. And you'll get those results within 24 to 48 hours. Plus, you don't need insurance or a doctor's referral.

It's simple. Just order your Sjögren's syndrome test, have your specimen collected by your local chosen patient service center, and receive your results in your online patient portal in 1 to 2 business days.

The sooner you get started, the sooner you'll have your answers.

So, what are you waiting for? Get started today and take charge of your health with Ulta Lab Tests.