SAGE Oncotest™ Requisition Form

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Patient Information

Patient Name
Test Requested

Ordering Physician

Physician Name

Biopsy Sample Requisition

I am hereby requesting for my patient a fresh biopsy sample obtained during

to be sent to SageMedic Corp to perform the SAGE HT Oncotest™. Please provide a fresh sterile sample using the SAGE shipment kit, activate the cooling mechanism, and use the FedEx return label for overnight shipment.

Patient Consent

I have explained to the patient the purpose, risks, and benefits of the test being ordered for clinical care and/or study participation and I have obtained patient informed consent for SageMedic to (a) perform the test described in this form, (b) obtain, receive, and release, test results, and any corresponding medical information as necessary; (c) and retain and use samples and information obtained, including the test results, for an indefinite period of time.

Indication

The SAGE HT Oncotest™ is a cytometric profiling and drug resistance test of the patient’s fresh biopsy and the purpose is to obtain additional information for providing standard of care according to applicable guidelines, specifically for the consideration of the upcoming

Indications

Patient History and Drug Panel

Primary Tumor Location
Current Staging
Biomarker, including Genomic Mutations (if known)
Past and Current Surgical, Radiation, and/or Systemic Treatments
Tumor Specific Drug Panels or Individually Selected Drugs*
Checkboxes

The undersigned represents that he/she is a licensed medical professional authorized to order patient testing, acknowledges that the patient has been supplied with all relevant information regarding the SAGE Oncotest™, including risks and benefits, and that the patient has given consent for the test to be performed. I request laboratory interpretation of these results and confirm that this may be used in the medical management and treatment decisions for this patient

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