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Pharmacokinetics Test Requisition Mount Sinai Genetic Testing Laboratory Mount Sinai Medical Center PATIENT INFORMATION: Patients Name: Last Gender: Male Female First Ethnicity: Caucasian African
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How to fill out pharmacogenetics test requisition mount
How to fill out a pharmacogenetics test requisition form:
01
Start by writing your personal information on the top of the form, including your full name, date of birth, and contact information.
02
Fill out the physician information section, providing the name of the healthcare provider who ordered the test and their contact details.
03
Indicate the reason for the test by selecting the appropriate box or providing a brief description in the designated space.
04
Specify the type of specimen you will be providing for the test, such as blood, saliva, or tissue.
05
If applicable, provide details about the prescription medications you are currently taking, including the drug name, dose, and frequency.
06
Include any relevant medical history or family history that may impact the interpretation of the results.
07
If there are other specific instructions or requirements, follow them accordingly, such as fasting before the test.
08
Review the filled-out requisition form for accuracy and make any necessary corrections or additions.
09
Sign and date the form, acknowledging that you understand and consent to the test.
10
Keep a copy of the completed requisition for your records.
Who needs a pharmacogenetics test requisition form?
01
Individuals who are experiencing adverse drug reactions or unusual medication sensitivities may benefit from a pharmacogenetics test. This test can help identify genetic variations that may affect the way their bodies metabolize medications.
02
Patients with chronic or complex medical conditions who require multiple medications may benefit from a pharmacogenetics test. It can provide insights into how their genetic makeup may impact their response to specific drugs, optimizing the treatment plan.
03
Healthcare providers, such as doctors or pharmacists, may request a pharmacogenetics test requisition form when they suspect a patient may have specific genetic factors influencing their medication response. This helps guide personalized treatment decisions and tailored drug prescriptions.
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