Home Page - Straticyte.Test.Referral

PATIENT INFORMATION

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ORDERING PHYSICIAN

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TEST REQUESTED

Straticyte – Uses a probability algorithm developed from an annotated cohort of reference cases to assess the 5-year probability of an oral potentially malignant lesion progressing to oral squamous cell carcinoma. It provides supplemental information for the corresponding pathology report. This test is not appropriate for lesions diagnosed as carcinoma.

SPECIMEN INFORMATION & RETRIEVAL

Surgical Specimen/Accession #:

Pathology Report:

AUTHORIZED SIGNATURE

Ordering Physician Signature:

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By typing my name, I hereby authorize testing and confirm that informed consent has been obtained from the patient for relevant information to be sent to Proteocyte for testing. I hereby attest that the person listed in the Ordering Physician space above is authorized by law in the relevant jurisdiction to order the test requested herein. By typing my name on this form, I attest the patient meets the inclusion criteria stated in the Test Requested section above, the clinical information described on this form is correct and belongs to the patient named above. I have had a discussion prior to testing regarding the potential results of the test and determined to use the results to guide patient management.

BILLING/PAYMENT INFORMATION

Payment Collected at Office

Payment Collected by Proteocyte