Oncotype DX Requisition Form for Invasive Breast Cancer and Ductal Carcinoma in Situ
Section I. Ordering Physician
Requisition Form Instructions
Complete all sections of the Requisition Form. Missing information will result in delays in test results.
Pathology Report and Patient Consent/Payment Form must be uploaded in Section 12 in order for this request to be processed.
Oncotype DX® results will be delivered to the ordering physician and additional recipients according to the preferences on file at Genomic Health, Inc. (GHI). Doctors will be notified via email to log onto the portal when results are available. For assistance in setting up an Online Portal Account for online ordering or to change your report delivery preference, please contact Customer Services at the number listed below.
In some cases, Genomic Health may use additional assessment methods, including confirmatory testing for HER2 status, to verify that the specimen meets the criteria for the Oncotype DX test.
NODAL TISSUE CANNOT BE TESTED AND WILL BE RETURNED
Customer Service Contact Information Phone: 1300 798 820 or +61 3 9859 1493 Email: customerservice@stbiopharma.com
The Ordering Physician should be the physician treating the patient or ordering on behalf of the physician.
The Office Contact for each physician may be contacted for any missing data follow-up or as needed to process the order.
ADDITIONAL PHYSICIAN / PATHOLOGY - If another physician is responsible for the care of this patient and has requested a copy of the report, enter the information in the applicable spaces provided under this section.
