Patient Information
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Physician Information
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Specimen Information



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Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option

PHYSICIAN SIGNATURE:

The ordering authorized Health Care Provider understands and hereby acknowledges that (a) the tests ordered are medically necessary for this particular patient, given the patient’s clinical condition, and have been recorded in the patient’s clinical file Read more

PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

By selecting the Add Signature button, I attest that I approve of this digital signature

By my signature below I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering physician/facility, however such results shall be used solely for clinical diagnostic/treatment purposes only and shall not be used for any forensic purposes related to my Read more
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Physician Signature / Date

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Patient Signature / Date