1 Name of the Patient *
2 Patient diagonis is Breast Cancer/ Colon cancer / Prostate Cancer *
3 Date of Birth of the Patient (dd/mm/yyyy) *
4 Date of Surgery of the Patient (dd/mm/yyyy) *
5 Contact No. of the Patient *
6 Patient's Address *
7 Email ID of the Patient *
8 Patients Gender Male or Female *
9 ER STATUS (incase Patient is breast cancer) / if colon please mention Stage / Prostate Cancer *
10 Tumor Size (not important for Breast Cancer Patient & Prostate Cancer Patient)
13 Micromets pn1mi (0.2 - 2.0mm)
14 Node + (Positive) 1-3 * (if node positive)
15 Node + (Positive) 4+ * (if node positive)
16 HER2 STATUS (incase Patient is breast cancer) *
17 Your Breast diseases is Primary (Yes / No) *
18 Block/Specimen No. *
19 Block returning location / address if sending PEFT block to GHI
20 Name of the Hospital or Institution where the tissue block is available
21 Please send patients IHC Report copy to us/ Histopathology Report copy *
22 Patient’s hospital Case no. where patient is operated
23 Name of the ordering Physician *
24 Name of the Institution where Physician is Practicing
25 Physician's Address :
26 Physician's Email ID
27 Physician's Phone no.
28 Physician's Fax no.
29 Please contact Blue Dart courier on +91 22 28241234 to pickup Block & Requisition form to send us on our address Medilinks Inc, Noble House, Office No. 03, Gr. Floor, Dr.Batliwala Road.,Parel, Mumbai -400012
30 Please feel free to contact for any query on + 91 22 49203000-06 /+91 8080901234 or on email : /
31 Kindly note that courier charges for sendig block & form will be reimbursed   
32 Report will be released directly to your physican within 18 days after we received the block 
33 Dear, Have you completely understood the process of the test and cost of the assay and your decision to go for the test or not, If Yes/No kindly mention in the answer column so that we can start the process accordingly. *
34 Report may delay due to technical reasons, we will inform timely or due to Late payment made by Patient. Patient is require to make payment within 3 days from the date the specimen reach US.
35 Block would be returned to Patients only strictly and you have to give Acknowledgement for the same if taken to prepare slides BUT slides wont be returned as they are sent to GHI for testing ( Kindly Agree )

NOTE : All star marked fields are mandetory

Ordering Form
Physician Details:
Patient Details:

Oncotype Dx:
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