Pharmacogenetics (PGx) Testing Requisition Form
LABORATORY TEST ORDER
Test(s) being ordered
Comprehensive PGx panel
Cardiovascular PGx Panel
Psychiatry PGx panel
Pain PGx panel
Oncology PGx panel
Pediatric PGx panel
Targeted PGx testing for specific genes
Specify gene
Indications for Test
ICD-10 Diagnosis Code(s)
PATIENT INFORMATIO
N
Last Name
First Name
Middle Initial
Date of Birth
(MM/DD/YYYY)
Biological Gender
Male
Female
Telephone Number
Is this a cell number?
Yes
No
Address
City
State
Zip Code
Email
Patient Insurance Information
Insurance Carrier
Policy ID number
Group number
Policyholder Name and DOB (if different than patient)
PROVIDER INFORMATION
Provider Name (First, Last, Credential)
Provider Practice Name
Practice Address
Practice City, State, Zip Code
Provider Phone Number
Provider Fax Number
M
EDICAL PROVIDER CONSENT:
I certify that the patient specified above and/or their legal guardian has been informed of the benefits, risks, and limitations of the laboratory test(s) requested. I have answered this person questions. I have obtained informed consent from the patient or their legal guardian for this testing.
Yes, I have read and I agree.
Provider Consent Date (MM/DD/YYYY)
Contact Information