Travera RTG EarlyAccess

Travera Rapid Therapy Selection™

TEST REQUISITION FORM
Is this a de-identfied sample?
By submitting this form I attest that I am an authorized provider, or am completing this form as a representative of an authorized provider. As may be required by applicable state laws and regulations, the patient has been informed regarding Travera’s testing and has consented for the test to be ordered. The patient has been informed that the result of their test will be interpreted as only one element in the medical decision-making process driven by their care team, and that those same results may be used or published by Travera in a deidentified manner in a manner that demonstrates the test’s performance characteristics.
For questions, please email: info@travera.com

Test Being Ordered and Specimen Information
Test and Specimen Type
Cancer Type
Anatomical Collection Site
For example: Left lung
Targeted Sample Collection Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For questions, please email: info@travera.com

Travera Rapid Therapy Selection™