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Mediclinic Precise - Pharmacogenetics Test
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*
) are required
Referring Clinician Information
Full Name
Clinician HPCSA
Telephone Number
Email
Practice Number
Patient Information
Id Number
Date Of Birth
First Name
Surname
Gender
Male
Female
Pregnancy status
Yes
No
Email
Mobile Number
Street Address
Suburb
City
Postal Code
Medication related information
This test is being requisitioned to confirm medication compatibility for treatment with the following medication(s):
Select Medications
This patient has experienced side effects or other issues with the following medication(s) in the past:
Please indicate any other relevant medications that aren't found in the dropdown menu
Other comments:
Lifestyle related information
This test can also consider the effect of lifestyle factors. Scientific evidence has shown these factors can affect the breakdown of medication. Does the patient consume any of the following on a frequent basis?
Acidic food
Alcohol
Caffeine-containing foods/beverages
Chamomile teas
Chocolate
Cranberry-containing foods/beverages
Enteral feeding
Fermented foods/sauces
Foods containing licorice
Foods containing milk
Foods high in calcium
Foods high in fat
Foods high in iron
Foods high in potassium
Foods high in protein content
Foods high in sodium
Grapefruit Juice
Leafy greens
Marijuana
Smoking
Tobacco
Tonic water
0/22 selected
Person Responsible For The Account
Same as patient
Id Number
First Name
Surname
Mobile Number
Email
Street Address
Suburb
City
Postal Code
By ticking this box, I, the healthcare provider, confirm the following:
*
The results of this test will be used for educational and information purposes only and I, the healthcare provider, am still required to make the final decision on treatment within the full clinical context of the patient.
This patient has been informed about the details associated with the genetic test ordered, including its risks, benefits and limitations, and has given consent to testing. The patient acknowledges and agrees to the cost of the test, and agrees to settle any and all invoices issued to them by Mediclinic, before the sample will be processed.
Date: 09/05/2024
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Select medications
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