SAGE Oncotest™ Specimen Form For the Biopsy Providing Physician

Please enable JavaScript in your browser to complete this form.

Layout

Patient Name

Patient Date of Birth

Patient Phone Number

Patient Email

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.

Biopsy Providing Physician

Pathologist Name

Specimen

Date of Biopsy

Location of Biopsy

If Biopsy Location Selected Above Is "Other" Please Specify Location

Surgically excised biopsy (ideally 1 gram or more, i.e. hazelnut size)

Core Needle Biopsy Needle Size

# of Cores

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

Layout

Biopsy Providing Physician Name

Institution

Phone

Email/Fax

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.

Physician Signature

Date of Physician Signature

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