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Patient Information
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Physician Information
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      Please Select Insurance Type and add Primary Insurance Provider for Testing Options

      Testing Option
      PATIENT CLINICAL AND LIFESTYLE HISTORY



      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 and that the Health Care Provider is responsible for assigning 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 Above 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 Read more
      PATIENT
      PROVIDER
      Insurance Detail
      COLLECTION DETAILS
      DIAGNOSTIC CODES
      MEDICATIONS
      PGx Test Order
       
      PATIENT CLINICAL AND LIFESTYLE HISTORY
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      Physician Signature / Date

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      Patient Signature / Date