Test Requisition Form (TRF)

Coupon No:

Test Name: Free TARGT First

PATIENT CONSENT

I hereby voluntarily consent to test for the presence of genomic mutations from collected samples.

By agreeing to undergo this test, I acknowledge and confirm that:

I have understood the information provided to me by my Doctor regarding the test.
This test will be performed by a third-party testing laboratory which will be solely responsible for the accuracy of the test results.
Cancer Research and Statistic Foundation or LuNGS Alliance supporting partners AstraZeneca, Roche, Pfizer, Bristol Myers and Sqibb and Eli Lilly does not perform any laboratory testing and therefore is not responsible for the test results.
I understand that I can avail this Test at any other laboratory other than the laboratories specified in this Test Coupon.
Aggregated data (without patient identifiers) may be analysed for trend analysis and/or presented/published in congresses/journals.

DOCTOR INFORMATION

*Referring Doctor:

*Contact No.:

*Email ID:

*Referred Hospital:

*City:

* I hereby confirm that I have provided accurate information regarding this test to the patient and the patient has provided his/her consent to undergo the test. Aggregated data (without patient identifiers) may be analysed for trend analysis and/or presented/published in congresses/journals.

*Date:

*Referring Doctor
Signature:

*Mandatory Information