Drug Metabolism Test Requisition Form

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Ship to:
285 Newton Road, 5296 CBRB
Iowa City, IA 52242-1078
Phone: 319-335-3688
Fax: 319-335-3484
Drug Metabolism Test Requisition Form
Patient Information
Specimen Information
Specimen Collection Date: ____ /____ / ______
MM / DD /
YYYY
Specimen Type: ☐ ~6mL EDTA whole blood
- Place patient ID sticker here -
☐~3mL EDTA whole blood (pediatric)
MRN:
Accession #:
-OR-
Test Menu
Pharmacogenomic Test for Drug Metabolism
______________ __________________
Name:
Select one or more options:
Last
First
☐Opioid Medications (CYP2D6)
____ /____ / ______
DOB:
Sex:
Male
☐Clopidogrel (Plavix®) (CYP2C19)
Female
MM / DD /
YYYY
Clinical Indication for Testing:
ICD-10 code:
Race and Ethnicity
Reporting Information (Fax# Required to Send Results)
Health Care Provider:
☐American Indian or Alaska Native
☐Asian
NPI:
☐Black or African American
Institution:
☐Native Hawaiian or Other Pacific Islander
Street Address:
☐White
Hispanic or Latino? ☐Yes ☐No
Zip:
City:
State:
Phone:
Fax:
Billing Information
Additional Report Recipient (Fax# Required to Send Results)
**NOTE: Institution billing ONLY. We do not bill patients
Health Care Provider:
directly. Credit cards are not accepted at this time.
NPI:
☐ Check here if institution and billing address are the same as
Institution:
above. Please enter a billing contact name below.
Street Address:
Billing Contact:
Zip:
Institution:
City:
State:
Street Address:
Phone:
Fax:
City:
State:
Zip:
CPT Code: 81225, 81226
Phone:
Fax:
Shipping Instructions
Samples will be accepted Monday-Friday. Do not ship for Saturday delivery.
Samples should be stored and shipped at ambient temperature.
IIHG ID#_________
For office use only
If you have questions please contact the IIHG at 319-335-3688 or
iihg@uiowa.edu
Rev. 1 Apr 2015
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