Questions?
Order Form
1801 Murchison Dr., St. 128, Burlingame, CA 94010 Toll-free phone: (844) 362-6567 Email:
[email protected]
PATIENT INFORMATION
Patient’s first name
Sex
Fax back to (650) 396-3046
Patient’s last name
Date of birth
City and state of residence
Patient’s email address (to send requisition # to)
Patient’s phone number
REASON FOR TESTING Patient will provide health history online
MRN
Screen for mutation that increases breast/ovarian cancer risk. Screen for mutation known or suspected to run in the family. Fax in relative’s report if possible. Affected gene
Lab where mutation was identified
Specific mutation (if known)
Other reason
PRIMARY CONTACT
Healthcare provider name
Role or title
Healthcare provider contacted first regarding any order details
Phone #
Fax # (for results delivery)
Email address
NPI #
Institution or practice
City and state
ORDERING PHYSICIAN
Healthcare provider name
If different than primary contact
Phone #
Fax # (for results delivery)
Email address
NPI #
Institution or practice
City and state
ADDITIONAL RECIPIENTS Healthcare providers involved in patient’s care
Healthcare provider name
Fax # (for results delivery)
RELEASE RESULTS TO PATIENT
When they are released to me
TEST REQUESTED
Breast and ovarian cancer risk analysis
Email address
After 5 business days
After 20 business days
In the case of a positive result, do not require genetic counseling by a board-certified genetic counselor at Color.
By completing this requisition, I certify that I am the ordering physician or I am authorized by an ordering physician to order this test, or that I am authorized under applicable state law to order this test. I further certify that the patient listed above agreed to receive communication about this order by Color. Furthermore, additional results recipients information is true and correct to the best of my knowledge.
Ordering physician signature Color Genomics, Inc. © 2016 (844) 362-6567 |
[email protected]
CLIA #05D2081492 - CAP #8975161
Date Version date: 1/11/16
