SAGE Oncotest™ Specimen Form For the Biopsy Providing Physician

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I have obtained a fresh and sterile tissue sample per Biopsy Providing Physician order,* that is to be shipped cooled overnight per shipment instruction to SageMedic Corp., a California-registered CLIA lab.

Specimen
DO NOT PLACE THIS SPECIMEN INTO FORMALIN.
See Shipment Instructions On The Next Page.

The undersigned represents that he/she is a licensed medical professional authorized and acknowledges that the patient has been supplied with information regarding the risks and benefits of obtaining the biopsy sample, and that the patient has given consent to the procedure and the biopsy being sent to SageMedic for testing.

*It is assumed that this tissue that is being sent to SageMedic is not essential for standard diagnostic workup.

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