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Clinical Genomics Test Requisition Form - Page 1 of 5

Clinical Genomics Test Requisition Form - Page 1 of 5 2025

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The document is a Clinical Genomics Test Requisition Form for Exome Sequencing and Microarray testing, detailing the necessary patient and specimen information, ordering physician details, insurance billing requirements, and informed consent for genetic testing. It includes sections for family member information in trio orders, clinical indications for testing, previous studies, and specific tests being ordered. The form emphasizes the importance of complete and accurate information to avoid delays in processing.

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