Patient Information (Please Print)

1 MEDICAL DIAGNOSTIC LABORATORIES, 2439 Kuser Road Hamilton, NJ 08690-3303. (609) 570-1000 Fax (609) 245-7665. Toll Free (877) 269-0090. Core OB/GYN Test Requisition Form Ordering Physician/Laboratory Pathology Test Selection (Required: Include the ordering physician's first & last name, NPI, practice name, complete Date Collected (Required): Specimen Source: address, phone number and fax number.). Anatomic Source (Required): Cervix/Endocervix Vagina Vaginal Cuff Other: _____. Date of LMP: Previous Results: ASCUS CIN 1 Other: Normal LGSIL CIN 2.

2 Date of Last Pap: Reactive HGSIL CIN 3. Pathology Test Requisition with completed clinical Information must accompany specimen ThinPrep . Liquid Pap only Liquid Pap with HPV Options Ages 21 and older Ages 30 and older 1301 Liquid 1302 1301 with Reflex HPV if 1304 1301 with Pap test ASCUS or greater HPV. HPV Re ex Test: 714 HPV Type-Detect by Next Generation Sequencing High Risk Subtypes Only (Includes HPV Subtypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68). Infectious Disease Test Selection (female - cervical, vaginal, rectal, lesion).

3 ThinPrep orOneSwab (male - lesion, [urethral - special male swab required]). Testing by Real-Time PCR unless otherwise speci ed. To order panel components individually, select tests beneath the panel. 182 Aerobic Vaginitis (AV) Panel PCR (GBS, S. aureus, , E. faecalis). 127 Group B Streptococcus (GBS) Is the Patient pregnant? Yes No 184 Staphylococcus aureus Physician to receive additional result report: 141 Escherichia coli Physician's Signature: Date: 153 Enterococcus faecalis 166 Bacterial Vaginosis (BV) Panel PCR [A. vaginae, BVAB2, G.]

4 Vaginalis, Patient Information (Please Print) Megasphaera species (Types 1&2)] (with Lactobacillus Profiling by qPCR). Name (Last, First) (Required): 142 Atopobium vaginae In Care of: 164 Bacterial Vaginosis Associated Bacterium 2 (BVAB2). 132 Gardnerella vaginalis Patient Address: 165 Megasphaera species (Type 1 and Type 2). City: State: Zip: 560 Candida Vaginitis Panel (C. albicans, C. glabrata, C. parapsilosis, C. tropicalis). 551 Candida albicans Gender (Required): Female Male Date of Birth (Required): 559 Candida glabrata Patient SS#: Ethnicity : 558 Candida parapsilosis 557 Candida tropicalis Phone Number: 127 Group B Streptococcus (GBS) Is the Patient pregnant?

5 Yes No Email: 137 Group B Streptococcus (GBS) Antibiotic Resistance by PCR (OneSwab only). **(#127 Req.) Only check if Patient is penicillin-allergic and clindamycin/erythromycin Billing Information (Please include a copy of the front & back of card.) resistance determination is required for alternate treatment. Patient Billing Relation (Required): Diagnosis Codes (Required): 126 Herpes subtype (HSV-1, HSV-2). Insurance Billing Self Please provide ALL applicable diagnosis codes. _____ _____. 121 Leukorrhea Panel (N. gonorrhoeae*, C. trachomatis**, T.)

6 Vaginalis ). Path Lab/Hospital Spouse 105 Chlamydia trachomatis (**Reflex to azithromycin resistance by Pyrosequencing). Physician Account Dependant _____ _____. 167 Neisseria gonorrhoeae (*Reflex to antibiotic resistance by Molecular Analysis). Primary Insurance Carrier: 111 Trichomonas vaginalis ( Reflex to metronidazole resistance). Insured's Name (if not Patient ): 129 Mycoplasma genitalium ( Reflex to azithromycin & fluoroquinolone resistance by Insured's SS#: Insured's DOB: Pyrosequencing). Claims Address: 110 Treponema pallidum (syphilis).

7 Medicare, Medicaid or Policy ID#: 320 Ureaplasma urealyticum ( Reflex to fluoroquinolone resistance by Pyrosequencing). Employer/Group Name: Group#: MALE & FEMALE SEXUALLY TRANSMITTED INFECTIONS. Specimen Information Uro UroSwab (Urine specimens only) by Real-Time PCR unless otherwise speci ed Date Collected (Required): Specimen Source: 105 Chlamydia trachomatis (**Reflex to azithromycin resistance by Pyrosequencing). 121 Leukorrhea Panel (N. gonorrhoeae*, C. trachomatis**, T. vaginalis ). Pharmacogenomics Test Selection 129 Mycoplasma genitalium ( Reflex to azithromycin & fluoroquinolone resistance by Whole Blood or Buccal Swab- *Informed Consent form must accompany specimen.)

8 Pyrosequencing). 3101 Antiplatelet Agents-Aspirin, Cilostazol, Clopidogrel, Prasugrel, Ticagrelor (ABCB1, 167 Neisseria gonorrhoeae (*Reflex to antibiotic resistance by Molecular Analysis). CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, ITGB3, SLOC1B1). 3102 Statins-Atorvastatin, Fluvastatin, Lovastatin, Pitavastatin, Pravastatin, Rosuvastatin, 109 N. gonorrhoeae* & C. trachomatis**. Simvastatin (ABCB1, ABCG2, APOE, CYP2C9, CYP2D6, CYP3A4, CYP3A5, KIF6, 110 Treponema pallidum (syphilis). MTHFR, SLCO1B1) 111 Trichomonas vaginalis ( Reflex to metronidazole resistance).

9 3104 Thrombophilia-Susceptibility to Factor II, Factor V Leiden (F2, F5, MTHFR). 3105 Calcium Channel Blockers-Amlodipine, Nifedipine (CYP3A4, CYP3A5) Applicable for adolescent females who are not candidates for pelvic exams. 3106 Beta Blockers-Bufuralol, Carvedilol, Metoprolol, Propranalol, Talinolol, Timolol BRCA care Test Selection (ABCB1, CYP2D6, UGT1A1). 3201 Pain Management-General-Alfentanil, Codeine, Fentanyl, Hydrocodone, *BRCA care Testing - Whole Blood or Mouthwash Ketamine, Lomoxicam, Methadone, Morphine, Opioids, Oxycodone, Sumatriptan, To order panel components individually, select tests beneath the panel.

10 Tramadol (ABCB1, COMT, CYP2B6, CYP2C9, CYP2D6, DBH, OPRD1, OPRM1) BRCA care Test Requisition and Informed Consent forms must accompany specimen 3303 Antimetabolites-Cytarabine, Fludarabine, Mercaptopurine, Methotrexate, Silibinin (ABCB1, ABCG2, MTHFR, SLCO1B1, TPMT) 1241 Comprehensive Hereditary Breast and Gynecologic Cancer Panel: 19 genes 3306 Platinum Derivatives-Carboplatin, Cisplatin, Oxaliplatin, Platinum Compounds (gen) analyzed by Gene Sequencing and/or Deletion/Duplication Analysis (BRCA1, (ABCB1, ABCG2, CYP3A5, MTHFR, TPMT) BRCA2, ATM, BARD1, BRIP1, CDH1, CHEK2, MUTYH, PALB2, PTEN, RAD51C, 3310 Uracil Derivatives-Capecitabine, Fluorouracil, Folfox, Folox, Leucovorin, Tegafur, RAD51D, STK11, TP53, EPCAM, MLH1, MSH2, MSH6, PMS2).