PREDICTIVE PREVENTATIVE Test(s) Requested - labgenomic 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your last name, first name, address, city, state, zip code, telephone number, social security number, date of birth, gender, and race/ethnic identification.
3. Select the tests you wish to request under 'PHARMACOGENETICS' and 'INFECTIOUS DISEASES'. Ensure you check at least one box for each category.
4. In the 'Insurance Information' section, provide details about your insurance policy if applicable. Include a photocopy of all insurance cards.
5. Complete the 'Ordering Physician Information' by entering the physician's name, NPI number, practice details, and contact information.
6. Sign and date the form in the 'Patient Consent' section to authorize testing and billing. Make sure to review all entries for accuracy before submission.

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