Sample Submission Instructions. STEP 1: Complete the Test Requisition Form and Informed Consent

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1 STEP : Complete the Test Requisition Form and Informed Consent Please fill out all sections of the Test Requisition Form Patient Information Required fields are highlighted in yellow Patient Name (Last Name/First Name/Middle Initial) Patient Social Security Number (SSN) Patient Gender Patient Date of Birth Patient Address Collection Date (date specimen was collected) Today s Date (date of service) PHYSICIAN INFORMATION Physician Information Complete prescribing physician contact information (physician name, NPI #, practice name, address, phone/fax numbers). Billing Information Complete insurance information (Name, Group #, Policy #) Attach copy of insurance card (front & back) Clinical Information Please check all ICD-0 codes that apply Primary ICD-0 Secondary ICD-0 Attached clinical notes, especially current medications list Specimen Information & Medical Necessity Please check specimen type and specify quantity Physician MUST sign the Medical Necessity Statement Note: buccal swabs or saliva sample MUST be submitted with each test requisition form for testing to be performed. PGxOnePlus CYPD, CYPC9, CYPA, CYPC9, DPYD, F, GPD, HLA-B, INFL, SLOCOB, TPMT, UGTIA, VKORC, ATM, CYPA, CYPA, CYPA, CYPF, F, DDRGK, ITPA, LDLR, MTHFR, NAT, STK Page - Front Submission Instructions Affix barcoded stickers to all sample tubes and additional forms (clinical notes/current medication list, insurance info, etc Informed Consent Physician Signature Physician MUST fill out his/her name and patient s name Physician MUST sign and date form Informed Consent Patient Signature Patient indicates how he/she wants his/her sample and information used (check Yes or No box) Patient MUST print name and sign and date form 8 Page - Back View PGx Sample Submission Video at admera

2 STEP : Sample Collection - Buccal Swab! Do NOT eat, drink, or brush teeth for hour prior to specimen collection. Collection should be performed by trained personnel. Print patient name and date of birth on the tube label using ball point pen or permanent marker. Affix one barcode sticker from the test requisition form to unlabeled portion of each swab tube. Patient should rinse mouth with water immediately before specimen collection. a b!! 0 seconds 0 seconds on cheek on gum Twist off and gently pull the cap to separate the swab from the clear plastic tube. Do not to touch the white swab head with your hands or fingers during process. With sufficient pressure, rub and rotate the swab, sweeping across the cheek and gum, for a minimum of one minute. 0 seconds on cheek and 0 seconds on gum Ensure entire swab head makes contact with patient's cheek and gum. Do not to touch swab head against patient s teeth, lips, or any other surface. 7 8 Carefully reinsert the swab into the clear plastic tube, leaving it partially open to air dry swab for minutes. Once dry, press the cap firmly to secure. Repeat Steps -7 using swab on alternate side inner cheek and gum. Swabs are intended for single use only. Store swabs at room temperature. View PGx Sample Submission Video at admera

3 STEP : Sample Collection - Saliva! Rinse mouth with water 0 minutes prior to providing a saliva sample. Do NOT eat, drink, smoke, or chew gum until finished with saliva collection. Hold Sample Tube upright. Spit into the Funnel until saliva level (excluding bubbles/foam) has reached the fill level marked on the Sample Tube. This may take a few minutes. Remove cap from the Dropper Bottle, and empty the contents into the Saliva Collection Device. Unscrew the Funnel from the Sample Tube and discard. Be careful not to spill any of the liquid. Screw the Tube Cap onto the Sample Tube until it is tightly sealed. Mix gently by inverting the Sample Tube to 7 times. The saliva mixture is now ready to ship or store. SalivaGard DNA can be stored at room temperature for up to months prior to use. This product is intended solely for the safe collection of saliva samples. Do NOT ingest SalivaGard DNA solution. If this solution comes in contact with eyes or skin, wash affected areas thoroughly with water. STEP : Sample Collection - Blood Draw at least mls of blood in lavender top vacutainer. This tube contains EDTA as an anticoagulant. Immediately invert the tube 8 to 0 times. Inversion ensures mixing and anticoagulation of the sample admera

4 STEP : Sample Collection Oral Rinse Do NOT eat, drink, or brush teeth for 0 minutes prior to specimen collection. Collection should be performed by trained personnel. Print patient name and date of birth on the tube label using ball point pen or permanent marker Apply one barcode label to the collection tube. Fill the measuring cup near the top with mouthwash. Pour ALL of the contents of the cup intro your mouth and swish vigorously for at least seconds. Spit ALL of the mouthwash from your mouth into the collection tube. TWO COLLECTIONS REQUIRED! Repeat steps, and adding to the same collection tube. Confirm that the collection tube is filled at least to the 0ml line. Replace the cap on the collection tube and screw on tightly. NOTE: If you are not going to ship your sample immediately, store the collection tube in the refrigerator at º C. DO NOT freeze admera

5 STEP : Packaging and Shipping Instructions Insert the completed, signed test requisition form, signed informed consent, and supporting documents into the pouch on the outside of the biohazard bag. Insert closed, labeled sample tubes ( buccal swabs, saliva, bood, or oral rinse sample) into the biohazard bag and seal. Insert the biohazard bag into the pre-addressed FedEx clinical shipping package. Arrange FedEx pickup or bring to FedEx drop box or facility for shipping to Admera Health. Or If using saliva or blood, place the biohazard bag into box (blood samples; include cold pack) and insert box into above package. Package can hold multiple samples. The completed test requisition, signed informed consent, and labeled sample tubes must be submitted for testing. Missing information will result in delays admera