Authorization Letter for collection of Specimen
for
Oncotype DX® Breast Recurrence Score Test

Date:

To
The Histopathology Department,

Name of Hospital

City

Subject: Request for Paraffin Embedded Tumor Tissue Block / Unstained Slide of the patient

Ms.
Case No.:


Dear Doctor,

I
had undergone Breast Cancer Surgery operated

by Dr.
on Date

My doctor had suggested ordering the Oncotype DX Breast Recurrence Score® test. For the test we require

  • Paraffin Embedded Block Containing the Invasive Tumor Tissue
  • 15 Unstained Slides using charged slides (For more information, please refer pathology guideline for slides making.)
  • Please Provide Specimen to Me or my relative Mr./Ms.

  • I have authorized the representative of Medilinks Inc. to collect the specimen on my behalf.

I am requesting you to kindly release the specimen.

Thank You.

Yours truly,

Name of Applicant

Contact Number

Email ID


(Computer Generated Request Signature Not Require)



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