SAGE Oncotest™ Requisition Form

Patient Information

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Patient Name

Date of Birth

Email

Gender

Phone Number

Diagnosis ICD10

Test Requested

SAGE HT Oncotest™

Ordering Physician

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Physician Name

First

Last

Phone/Fax

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Institution

Email

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Lab Reference #

Physician’s NPI

Address

Address Line 1

Address Line 2

City

State

Zip Code

Biopsy Sample Requisition

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

the upcoming surgery,
the upcoming diagnostic procedure,* or
a procedure conducted for the sole purpose of obtaining this biopsy, and

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.

*Note that a core needle biopsy must have at least two 12 gauge needle cores of at least 1 cm of malignant tissue.

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

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Payment

The SAGE HT Oncotest™ does not have a reimbursement code, so costs will be covered by one of the options below.

The patient signed a purchase order and agreed to pay SAGE for the SAGE HT Oncotest™.
The patient signed up for a pilot study and agreed to pay SAGE for participation and the SAGE HT Oncotest™.
The cost for the SAGE HT Oncotest™ is waived, e.g. the patient is a physician or for a limited trial period.

Patient History and Drug Panel Form

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Patient Name

First

Last

Diagnosed on

Date of Birth

Primary Tumor Location

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Current Staging

Histology Type (if known)

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Biomarker, including Genomic Mutations (if known)

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Past and Current Surgical, Radiation, and/or Systemic Treatments

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Tumor Specific Drug Panels or Individually Selected Drugs*

Basic Panel
Advanced Panel
Premium Panel

*See attached sheet of tumor specific panels. Note that all in-vitro assays have false positive and false negative results and can never be perfect predictors of clinical responses. Thus, the SAGE Oncotest™ should be used to assist the clinician in deciding between therapies which, in the absence of these results, are all considered to be equally acceptable: “Going beyond standard of
care within standard of care!”

In special cases, e.g. exhaustion of standard therapy, a specific drugs or a set of drugs may be ordered

4 Drug Panel
6 Drug Panel
8 Drug Panel with Targeted Therapies

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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

Signature

Date