Test Requisition Form (TRF)
Coupon No :
Sample Information
Formalin-Fixed Paraffin-Embedded ( Lung FFPE Block )
Block No :
No. Of Blocks :
Laboratory Information :
*Please tick Patients Clinical evaluation and Stage
*PD-L1 Testing Requirements:
Test Name :
TARGT First + PD-L1 (SP263)
TARGT First + PD-L1 (SP263)
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:- 1. I have understood the information provided to me by my Doctor regarding the test.
- 2. This test will be performed by a third party testing laboratory which will be solely responsible for the accuracy of the test results.
- 3. Cancer Research and Statistic Foundation or LuNGS Alliance supporting partners AstraZeneca, Roche or Pfizer does not perform any laboratory testing and therefore not responsible or liable for my test results.
- 4. I understand that I can avail this Test at any other laboratory other than the laboratories specified in this Test Coupon.
- 5. Aggregated data (without patient identifiers) may be analysed for trend analysis and/or presented/published in congresses/journals.
DOCTOR INFORMATION
*Reffering Doctor :
*Contact No :
*Email Id :
*Referred Hospital :
*City :
- I hereby confirm that I have provided accurate information regarding the 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.
Patient INFORMATION
*Patient's Name :
*Gender :
*Age :
*Contact No :
*City :
*Email :
*Date :
* Mandatory Information
:
*Reffering Doctor Signature*Date :
:
*Patient's Signature / Thumbprint
Patients Copy
Coupon No :
TERMS AND CONDITIONS
- One coupon will be valid for only one test.
- The validity of the coupon is 45 days from the date of issue.
- The test is Provided at free of cost and no payment to be made.
Test Name :
TARGT First + PD-L1 (SP263)
TARGT First + PD-L1 (SP263)
CONTACT DETAILS
18002022455
info@4basecare.com
Working Hours 10:00 AM - 7:00 PM, Monday to Friday
An initiative by:
Supported by:
Lab Partner:
