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Hereditary Cancer
Test Request Form page 1 of 2Please submit both pages of this form
Make sure information is complete and legibleSPECIMEN COLLECTION DATE (REQUIRED)FOR LAB Used i ii i i i(MM/DD/YYY)1.
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How to fill out hereditary cancer test request

How to fill out hereditary cancer test request
01
Step 1: Obtain the hereditary cancer test request form from a certified genetic counselor or healthcare provider.
02
Step 2: Fill out the personal information section, including your name, date of birth, gender, and contact details.
03
Step 3: Provide your medical history, including any family history of cancer, types of cancer, and ages of diagnosis.
04
Step 4: Answer the questions about your personal history of cancer diagnosis, if applicable.
05
Step 5: Sign the consent form to indicate your agreement for the testing and release of information.
06
Step 6: Submit the completed hereditary cancer test request form to the specified laboratory or genetic testing company.
07
Step 7: Follow any additional instructions provided by the laboratory, such as payment details or appointment scheduling.
08
Step 8: Wait for the test results to be processed and delivered to your healthcare provider.
Who needs hereditary cancer test request?
01
Individuals with a family history of cancer
02
Individuals who have been diagnosed with cancer at a young age
03
Individuals with multiple primary cancers
04
Individuals belonging to high-risk ethnic groups
05
Individuals who have had multiple family members diagnosed with cancer
06
Individuals with certain genetic conditions that increase the risk of cancer
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