ColoScape™ Test

Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
*Gender*
Geoancestry/Ethnicity
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
*Phone*
Email*
I acknowledge*
This test might be right for me if I am (1) at average risk of colon cancer; or (2) symptomatic of colon cancer; or (3) previous positive FIT/FOBT test
Check all that apply. If “I have none of the above” is selected, you are considered at average risk and ColoScape Test can be ordered. If you have one or more of boxes selected, you are not considered an average risk and ColoScape Test cannot be ordered.*
- No personal or family history of colon cancer
- No positive result from past colon cancer screenings
- No personal or family history of gastrointestinal conditions and cancers including: Attenuated familial adenomatous polyposis (AFAP); Cowden syndrome (CS); Gardner syndrome; Hereditary non-polyposis colorectal cancer (HNPCC or Lynch syndrome); Hyperplastic polyposis syndrome (HPS); Juvenile polyposis syndrome (JPS); MUTYH-associated polyposis (MAP); Neurofibromatosis (NF); Peutz - Jeghers syndrome (PJS); Turcot/Crail syndrome
- None of the above
Check all symptoms that apply for you. If you have any of the symptoms ColoScape can be ordered. If you do not have any of the symptoms ColoScape cannot be ordered.*
- Rectal bleeding or blood in stool
- Pencil thin stool
- Unexplained weight loss
- Changes in bowel movements
- Feeling Constipated
- New or worsening belly pain
- Colon cancer or family history of colon cancer
- A history of gastrointestinal cancer or condition
- None of the above symptoms
FIT or FOBT Test (A FIT or FOBT test looks for blood in stool)*
- Yes. I had a FIT / FOBT test and the results was positive (can order ColoScape)
- Yes. I had a FIT / FOBT test and the results was negative (cannot order ColoScape, given that you are symptomatic)
- No, I have not had a FIT test (cannot order ColoScape Test)
Have you been screened for colon cancer with colonoscopy before?*
- Yes. I had a colonoscopy and the results was positive (cannot order ColoScape)
- Yes. I had a colonoscopy test and the results was negative (can order ColoScape)
- No, I have not had a colonoscopy (You can order ColoScape Test)
Consent*
I request and authorize the DiaCarta Clinical Laboratory to perform the requested test(s) for the person(s) listed above. I acknowledge the benefits, risks, and limitations outlined below. I understand that my specimen(s) will be submitted to DiaCarta for the purpose of lab testing. I authorize DiaCarta to store my specimen in case additional testing is necessary. The DiaCarta Clinical Laboratory does not return patient samples. I can request additional tests or send out samples to other institutions if there is enough sample. Once my test result has been released, remaining samples may be de-identified to be used for laboratory quality control or research. I can withdraw my consent at any time by calling the DiaCarta laboratory at (800) 246-8878. My signature below indicates that I have read the above information. All my questions have been answered and my inquiries regarding the purpose of this test have been discussed and fully understood by me.
Consent*
I authorize DiaCarta Inc. to obtain & release relevant medical and other information and to directly bill & submit claims to my insurance providers for laboratory services that DiaCarta provides to me. I assign insurance benefits to DiaCarta & acknowledge that charges not covered or exempt by insurance (e.g. no balance billing policies) including applicable co-payments & deductibles, are my responsibility & I agree to pay for such charges.*
*Patient Signature/Initial*
*Date*
Date Format: MM slash DD slash YYYY

ColoScape™ Test Patient

Inclusion/Exclusion Criteria

The following criteria will determine whether the ColoScape test is appropriate for you.

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