SAGE Oncotest™ Requisition Form

Please enable JavaScript in your browser to complete this form.

Patient Information

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.

*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.


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



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

Patient History and Drug Panel Form

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

*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

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