Note: All information with a red asterisk ( * ) must be completed
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.
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
Specific Site Analysis
Positive Control Not Available
Positive Control Sent/To Be Sent
Do not include BRCA1/2 sequencing results for this multi-gene panel order due to previous negative testing for this patient through another diagnostic laboratory. PLEASE NOTE: a copy of the previous negative BRCA1/2 report MUST be included with the test requisition form for BRCA1/2 sequencing results to be excluded from the final Aeon Clinical Laboratories report. In addition, clinically significant BRCA1/2 variants(i.e.those classified as “pathogenic” or “likely pathogenic”) are always reported.
Physician Signature / Date
Patient Signature / Date
*BRCA1 and BRCA2 Somatic testing also available