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FORM

Test Request

PATIENT

Sex
Payment Method

PHYSICIAN – CLINIC

SUBMITTED MATERIAL

SPECIMEN INFORMATION

SUBMITTED MATERIAL
The patient has undergone:
Diagnosis:

PATIENT CONSENT



As the undersigned, I hereby provide my consent to the private Histopathology and Cytology Laboratory MICRODIAGNOSTICS for the processing of my personal data within the framework of Regulation 2016/679, in accordance with the following: The purpose of the processing of personal data by MICRODIAGNOSTICS is exclusively the provision of the services requested by the patient. The personal data collected ensures the proper traceability of the diagnostic specimen. All personal data are processed by duly authorised personnel, with appropriate care for data protection through the implementation of a series of security measures. The data collected are not subject to any further processing beyond the purpose for which they were collected. Taking the above into consideration:

PATIENT CONSENT

The list of available tests is updated through a dynamic process in accordance with current scientific research. It should therefore be acknowledged that there is a possibility that the list of genes included in the order form may have changed — with genes being added or removed — by the time the sample is analysed in the laboratory. By signing this form, I acknowledge and accept that the list of genes actually analysed may differ from the current one.

DIAGNOSTIC AND MOLECULAR TESTS

Colorectal Cancer
Breast Cancer
Lung Cancer
Ovarian Cancer
Prostate Cancer
Broad-Use Multigene Oncology Panels
Melanoma
Soft Tissue and Bone Tumours
Glioblastoma
Pancreatic Cancer
Predisposition to Hereditary Cancer
Endometrial Cancer
Stomach Cancer
Cholangiocarcinoma
Bladder Cancer
Pharmacogenetic Tests
Thyroid Cancer
G.I.S.T. Tumour
Sexually Transmitted Diseases
Detects: Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Candida albicans, Candida glabrata, Candida parapsilosis, Candida krusei, Candida tropicalis, Treponema pallidum, Herpes Virus types 1 and 2.
STD
The microorganisms included are Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, Candida albicans, Treponema pallidum, Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Gardnerella vaginalis, as well as HSV-1 and HSV-2 viruses.
Typical and Atypical Mycobacteria
(M. tuberculosis, M. microti, M. avium, M. abscessus, M. chelonae, M. intracellulare, M. fortuitum, M. peregrinum, M. gordonae, M. kansasii, M. scrofulaceum, M. szulgai, M. terrae, M. celatem, M. mucogenicum, M. nonchromogenicum, M. shimoidei.)
HPV DNA TEST
Detects and genotypes high-risk HPV subtypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59; possibly high-risk subtypes 26, 34, 53, 66, 67, 68a, 68b, 69, 70, 73, 82IS39 and 82MM4; and low-risk subtypes 6, 11, 40, 42, 43, 44, 54, 55, 57, 61, 62, 72, 81CP8304, 83MM7, 84MM8, 90 and 91.
HPV APTIMA TEST
Through the expression of mRNA from the two oncogenes E6/E7, it detects high-risk HPV subtypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68, and genotypes 16 and 18/45.