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If you are a New Customer, please register before placing your order.
Registered customers, use the form below to place your order.

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Order Test

OmniSeq testing may be ordered by a liscensed ordering provider. Order the test prior to sending the test sample. Any incomplete fields may delay the start of testing. OmniSeq will manage specimen procurement and insurance verification.

If you are human, leave this field blank.

Ordering Provider Information

Provider Name/Credentials *

NPI# *

Hospital/Practice Name *

Street Address *

Apartment #

City *

State *

Zip *

Phone *

Fax

Email *

Patient Information

Patient's Last Name *

Patient's First Name *

Middle Initial

MRN# *

Date of Birth *

Gender *

Street Address *

City *

State *

Zip *

Home Phone *

Work Phone

May we leave a message on voicemail/answering machine? *

Yes

No

Clinical Indication

Select Test *

OmniSeq Comprehensive

OmniSeq Immune Report Card (Includes PD-L1 IHC)

Primary Tumor Site ICD-10 Code *

Primary Tumor Site Stage *

Secondary Tumor Site ICD-10 Code

Tumor Type *

Lung

Breast

Colon

Melanoma

Kidney

Other

Other Description:

History or Clinical Information to Support Medical Necessity of Testing

Reason for Testing *

New Diagnosis

Recurrent/Relapsed

Remission

Monitoring/Follow Up

MRD

Staging

BMT

Other

Other Description:

Current Cancer Treatment (Select all that apply)

New Diagnosis

Recurrent/Relapsed

Remission

Monitoring/Follow Up

MRD

Staging

BMT

Other

Other Description:

Additional Therapy Details

Specimen Information - FFPE Block Preferred

Please include a copy of the associated pathology report

Facility Where Block is Located *

Date of Procedure *

Specimen ID Number(s) *

Specimen Source *

Billing Information

**Complete billing information is required to begin testing. *Attach copies of front and back of insurance card(s).**

Has the patient been discharged from a hospital within the last 14 days? *

No

Currently Inpatient

Yes

Date of Discharge

Institution

Bill to *

Insurance

Self-Pay

Insured DOB *

Name of Insured *

Reset Signature

*

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