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Requisition form for specialty kits

Last Updated: May 20, 2015 04:14PM PDT
Attached are sample requisition forms (pdf. format) for ALCAT, ZRT Laboratory, SpectraCell, and Labrix. The highlighted areas are the areas that need to be completed by the patient.

For Genova Diagnostics / Metametrix:
There are a variety of requisition forms depending on test kit ordered. The only sections that need to be completed by the patient are:
1) Your personal information (e.g. first name, last name, middle initial, date of birth, gender, home address, phone number)
2) Billing information: check mark "bill healthcare practitioner account"
3) Check mark name of test ordered (Note: "Add on test" are at an additional cost. Please contact us if you want a "add on test")

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