Note: All information with a red asterisk ( * ) must be completed

Patient Information
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Physician Information
Billing Information




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 and the Health Care Provider is responsible for assigning and providing specific ICD-10 code(s) to support the medical necessity of any and all laboratory tests; and (b) the Health Care Provider must make a determination that medical necessity exists each time a specimen is submitted. 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 employment or other legal or administrative purposes. The specimen identified by this form is my own, is fresh and is unadulterated. Read more
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Physician Signature / Date

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Patient Signature / Date