Please Select Insurance Type and add Primary Insurance Provider for Testing Options
By ordering testing, the undersigned person represents that he/she is a licensed medical professional authorized to order genetic testing OR is a representative of a licensed medical professional authorized to order genetic testing; acknowledges the patient has been supplied information regarding genetic testing and the patient has given consent for genetic testing to be performed and the signed consent form is on file. I confirm that this is medically necessary for the diagnosis or detection of a disease, illness, impairment, syndrome or disorder, and that these results will be used in the medical management and treatment decisions for this patient. My signature here applies to the attached letter of medical necessity (if applicable). Furthermore, additional results recipients information is true and correct to the best of my knowledge.
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
I acknowledge that the information provided by me is true to the best of my knowledge. For direct insurance/3rd party billing: I hereby authorize my insurance benefits to be paid directly to Westside Surgical Hospital and authorize them to release medical information concerning my testing to my insurer. If applicable, I authorize Westside Surgical Hospital to be my Designated Representative for purposes of appealing any denial of benefits. I understand that I am financially responsible for any amounts not covered by my insurer for this test order. I also fully understand that I am legally responsible for sending Westside Surgical Hospital any money received from my health insurance company for performance of this genetic test.
No personal history of cancer
Personal h/o Breast Cancer
Bilateral
Check here if surgery is occurring within the month and Genetic results will impact surgery.
IDC (Invasive ductal carcinoma)
ILC (Invasive lobular carcinoma)
DCIS (Ductal carcinoma in situ)
LCIS (Lobular carcinoma in situ)
Personal h/o Ovarian Cancer
Personal h/o Pancreatic Cancer
Personal h/o Other Cancer
Personal h/o allogenic bone marrow or peripheral stem cell transplant
Current diagnosis of heme malignancy
Personal h/o Colon Cancer
Personal h/o Endometrial Cancer
Tumor testing previously performed
Stable (MSS)
Unstable (MSIDH)
Normal
Absence of:
Personal h/o Colon Polyps
Adenomatous polyps
Other polyps
No previous genetic testing
Negative BRCA1/2 gene sequencing only
Negative BRCA1/2 gene sequencing and large rearrangement
Negative Lynch syndrome genetic testing
Negative polyposis genetic testing
Other
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