Follow the steps to complete the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in today’s date in the designated field to indicate when the form is being completed.
3. Enter the patient information, including the patient's last name, first name, middle name, and birth date in the specified format (mm/dd/yyyy). Make sure all details match the patient's identification.
4. Record the sample collection date, ensuring it is in the correct mm/dd/yyyy format. This is critical for the processing timeline.
5. Input the patient ID number for further identification.
6. Indicate the patient's sex by checking the appropriate box for either male or female.
7. Specify the time of collection using the hh/mm format.
8. Select the reason for testing by checking the relevant box. If 'Other' is selected, please provide specifics in the space provided.
9. Fill in the ordering information, including the physician's name, department, hospital name, address, city, and country.
10. Complete the results delivery method by choosing to send results via fax or email, and provide the appropriate contact information.
11. Obtain the authorized physician's signature in the designated area, as this is mandatory for the requisition.
12. Select the type of test requested, either the 2-panel or 6-panel assay, and decide if a medical consultation is desired.
13. Fill out the patient medical information as required, providing any additional details necessary for the test.
14. Choose your billing option from the provided selection and fill in the institutional billing or international bank transfer details if applicable.
15. After completing all fields and ensuring correctness, save your changes. You can then download, print, or share the completed form as needed.

Complete your DE RepeatDx Requisition Form online to ensure accurate processing and timely results.