FRAT - Test Requisition Form

5110 Campus Drive, Suite 120/137 | Plymouth Meeting, PA 19462

T: 610-441-9050 | F: 610-537-5075 | E: info@fratnow.com | https://fratnow.com
New SampleReplacement Sample
Date Specimen Collected:

MonthDayYear
Date
Phlebotomist/Provider Initial Here:
SAMPLE INFORMATION (PROVIDER TO COMPLETE)
PLEASE NOTE: PATIENTS MUST NOT TAKE FOLINIC ACID OR 5-MTHF FOR 48 HOURS PRIOR TO BLOOD DRAW.
Speciment Type: Serum (SST - serum separator collection tube)
Diagnosis:
Diagnosis Codes:
EmailFAXOther
FACILITY INFORMATION (PROVIDER TO COMPLETE)
Provider Name:*

First NameLast Name
Facility Name:*
NPI:
Street Address:*
City:*
State/Region:*
Zip/Postal Code:*
Country:*
Phone:*
Format: (000) 000-0000.
Email:*
example@example.com
Secure Fax:
Provider acknowledgement: I hereby confirm that the information, including the information related to medical necessity as provided on this form, has been provided to the patient specified below and/or their legal guardian about the test(s) to be performed, and the patient specified below and/or their legal guardian has given consent for the test(s) to be performed. I confirm that the person listed as the ordering provider who has signed below is authorized by law to order the test(s) requested herein.
Provider Signature:*

Clear
Title:
Date Signed:*

MonthDayYear
Date
PATIENT INFORMATION
Patient Information:*

First NameLast Name
Date of Birth: (mm/dd/yyyy)*

MonthDayYear
Date
MaleFemale
Street Address:*
City:*
State/Region*
ZipPostal Code*
Country:*
Phone:*
Format: (000) 000-0000.
Email:*
example@example.com
YesNo
PAYMENT INFORMATION
Cost of FRAT® testing is $295 (please select preferred payment method PRIOR to testing)
Credit CardElectronic InvoiceCheck (payable to Religen Inc.)
Name on Card
Billing Zip/Postal Code
Expiration Date

MonthDayYear
Date
CVV
Check Amount
Check #
Email or Phone (SMS text) for Invoice:
Email for Billing Communications
example@example.com
PATIENT CONSENT & AUTHORIZATIONS

Patient acknowledgment: My healthcare provider has provided me with information regarding the tests requested on this form. I agree that I am voluntarily submitting this sample for analysis. I authorize my provider to release the sample and any other necessary records as requested to Religen Inc. and for Religen Inc. to release the results of FRAT® to the ordering provider. I understand that I am responsible for all charges for FRAT testing.
PATIENT/PARENT/GUARDIAN SIGNATURE

Clear
Date Signed:

MonthDayYear
Date
Responsible Party: (If other than Patient)
Relationship to Patient:
Religen Inc CLIA ID #: 39D2130307

Reference Lab: Vascular Strategies LLC CLIA ID #: 39D2109943

RI-FMS-0019 version 02; Effective date: 1/1/2025

FRAT® PATENT NO: US7,846,672 B2
Should be Empty:

5110 Campus Drive, Suite 120/137 | Plymouth Meeting, PA 19462

SAMPLE INFORMATION (PROVIDER TO COMPLETE)

FACILITY INFORMATION (PROVIDER TO COMPLETE)

PATIENT INFORMATION

PAYMENT INFORMATION