Diagnostics Test Requisition. I agree that I will contact a Genesis Molecular Diagnostics Representative without delay if, at any point in time, the test combination that makes up my Custom Profile no longer reflects the needs of my patients or if, for any reason, I would like to modify my
Customer Profile.
I understand that each individual test …show more content…
I understand the potential implications of ordering customized panels as described above and authorize Genesis Molecular Diagnostics to perform the Custom Profile I have created with this form, including each of the tests checked, each time I submit a specimen accompanied by a Test Requisition on which I have ordered my Custom Profile test option.
The use of a Custom Profile is offered to me as a convenience, but there is no requirement to establish one since any test I wish to order for a patient can also be ordered on Genesis Molecular Diagnostics’ standard Requisition forms. By signing this form, I acknowledge the stated understandings and