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Iversongenetics.com

19805 North Creek Pkwy, Bothell, WA 98011 SAMPLES WITHOUT CLIENT AND PATIENT ID WILL NOT BE PROCESSED I. Client Information (New clients complete shaded area)
II. Patient Information (Complete shaded area or attach information)
III. Billing Information
A copy of the front and back of insurance card (including Medicare and/or Medicaid) and patient demographics/face sheet must be attached

IV. Specimen Information
V. Iverson Assay Requested and Order Information
Specimen Collected:
DME Genotype Panel** (Drug Metabolizing Enzymes) ICD-9 Code(s):
*DME Extended Panel (CYP2C9, CYP2C19, CYP2D6, VKORC1, CYP1A2, CYP3A4, COMT) **DME Genotype Panel (CYP2C9, CYP2C19, CYP2D6, VKORC1) VI. Authorizations
To be medically necessary, diagnostic laboratory tests must be ordered by a treating
I hereby authorize the release of medical information related to this service for submission of personalized reports to my healthcare providers and insurance carriers. In addition, I agree to assume responsibility for payment of charges for laboratory services that are not covered by my healthcare insurer. No tests other than those authorized shall be performed on the biological sample and the sample shall be destroyed at the end of the testing process or not more than sixty days after the sample was taken, unless a longer period of retention is expressly authorized VII. Warfarin GenoSTAT Patient Profile (Only for new start warfarin patients 0-5 daily doses)
arfarin doses taken so far:
Liver Disease:
Indication: Diabetes:
Warfarin dose and INR data:
Vitamin K Level (Optional):
Baseline INR (Prior to first dose):
Target INR (if other than 2.5):
Amiodarone/Cordarone® Dose (oral): mg/day None
Statin/HMG CoA Reductase Inhibitor:
Yes If yes, please mark below
Atorvastatin/Lipitor®/Caduet®
Rosuvastatin/Crestor®
Fluvastatin/Lescol®
Simvastatin/Zocor®/Vytorin®
Ethnicity:
Lovastatin/Mevacor/Altoprev®/Advicor®
Pravastatin/Pravachol®
Asian, Indian SubContinent Native Hawaiian, Other Pacific Islander Any azole (eg. Fluconazole):
Caucasian, White, Middle Eastern Other: Sulfamethoxazole/Septra/Bactrim/Cotrim/Sulfatrim:
Weight: lbs. Height: ft. in.
Carbamazepine/Phenobarbital/Phenytoin/Rifampin:
For hip and knee arthroplasty or fractures, specify blood loss (if other than 10 ml):  ml    
WARNING: The above information and any reports generated therefrom are supplied at the request of the ordering healthcare professional using publically available information relating to Warfarin dosing estimates contained at www.warfarindosing.org. Iverson Genetic Diagnostics, Inc. makes no representations or warranties with respect to the information contained on www.warfarindosing.org. All information from this or any other publically available site should always be correlated with the clinical presentation of patients. The physician remains solely responsible for making decisions related to Warfarin.
From www.warfarindosing.org, a publically available site not affiliated with Iverson Genetic Diagnostics, Inc.

Source: http://www.iversongenetics.com/Iverson_Lab_Requisition_Form.pdf

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