PredicineCARE

Test Requisition Form Explainer

Affix barcodes here

and to the associ-
ated patient’s blood
tubes with 2 patient
identifiers
Patient information
must be provided
Provider information
Indicate the test
requested Include the specimen
type, ICD-10 code(s),
stage, and collection
date. Please list any
current or previous
therapies, date of
original diagnosis,
indication for testing
as well as selecting
the primary diagnosis
site.

Information on prior
molecular results
help to complete
For the Early Access the clinical picture of
Program, option 3 your patient.
has been preselected
and is valid through
January 31, 2022.

Provider signature is
required

To ensure the sample moves as quickly as possible to get the patient a result, please check these commonly missed items.
Barcode is affixed to the top of the TRF and the other barcodes are on the blood tubes with 2 forms of patient
identification (name and date of birth)
The ICD-10 code(s) and stage are indicated and collection date is noted
The primary diagnosis is checked
The provider’s signature

Predicine, Inc. | 3555 Arden Road, Hayward, CA, 94545, USA | (650) 300-2188 | care@predicine.com