The Sentara Selftest Brochure


Sentara SelfTest
Sentara SelfTest
Order Form
Patient Waiver
Sentara SelfTest
from Sentara Laboratory Services allows
I am directly and voluntarily seeking testing by Sentara Reference Laboratory. In order to perform the test(s), blood will be drawn
patients to proactively
monitor their health. Please choose from
from my arm using a needle inserted by a trained lab employee called a phlebotomist. I understand that as a result of taking blood
the tests listed below and pay any fees. We encourage you to
from my arm, some soreness, discomfort, or bruising may occur at the site where the blood was drawn, and occasionally more
share your results with your physician.
serious effects may happen related to nerve damage.
Basic Metabolic Panel (BMP) 6707
I understand that the tests I requested may not detect all abnormalities that may be present. For diagnosis and treatment of any
Blood Alcohol level - 6203
Start Monitoring
abnormality indicated by this testing, I must see my personal physician for a complete medical examination and for any questions
Cholesterol – 6617
relating to the results. If I do not have a physician, I may request one through Sentara HealthCare’s Physician Referral service at
Your Health Now.
Complete Blood Count (CBC) 12100
1-800-SENTARA. I understand and agree that all of my results from this testing may be included in my electronic medical record.
Complete Metabolic Panel (CMP) 10032
Drug Test Urine (5 Panel) - 7699
I acknowledge that I am solely responsible for arranging for any follow-up evaluation, interpretation, diagnosis, and treatment from
You can now order a wide variety
Hgb A1c -10931
my physician. Any results that are so far from the normal range that they require immediate attention will be labeled as “Critical
of medical testing that allows you
Ferritin - 7130
or Panic Values”. Should any Critical or Panic Values be reported in my results, I will be notifi ed by phone by the Pathologist. If
Glucose - 6601
I am called about a critical result I will immediately seek care from the nearest emergency room and/or call 911 for ambulance
to proactively monitor your health –
HDL Cholesterol - 6870
transportation if needed. The phone number I am providing to you can be used to communicate with me, or to leave a message
simply, securely and conveniently with
High Sensitivity CRP - 11800
indicating the urgent nature of the call. I am assuming the risk of delayed treatment or a missed diagnosis by having testing done
Sentara SelfTest. To take advantage of
Complete Lipid Profi le - 11001
without the supervision of my physician.
Urine Microalbumin - 10777
this service, testing information and
Pregnancy Test - 6158
I hereby release Sentara Reference Laboratory, the physicians and employees performing the testing from any and all liability arising
instructions are provided inside this
Prothrombin Time (PT) 1251
from or connected with the implementation of this testing, and for any problems caused by not sending the results to my physician
Prostate Specifi c Antigen (PSA) - 11051
brochure and on our website at:
for follow up on test results. I understand that this testing does not constitute a complete medical examination or diagnosis.
Testosterone - 7582
Thyroid Stim. Hormone (TSH) - 7250 $25
NOTICE OF DEEMED CONSENT FOR INFECTIOUS DISEASE TESTING: Virginia Code Section 32.1-45.1 provides that if anyone
Triglycerides - 6930
on our staff, when processing your specimen, is directly exposed to your blood or body fl uids in a way that may transmit human
Uric Acid - 6604
immunodefi ciency virus or Hepatitis B or C virus, we may test for those viruses and release the test results to the person directly
Urinalysis Screen 17500
exposed so that they may seek treatment if needed.
Vitamin B12 & Folate - 10631
Vitamin D - 8713
I have read this form and agree with its contents.
Total: $
Name: ___________________________________________
Participant Signature
Date of Birth: ______________________________________
Address: _________________________________________
Witness Signature
City, State, Zip: ____________________________________
For Registration use only: Client Code 5440
Primary Contact Phone: _____________________________
Rev. 03/15


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