Give us a call: 1 947 222 6237 Please enable JavaScript in your browser to complete this form. - Step 1 of 8Let’s get started Please fill in your details to begin the questionnaire. Your information is private, confidential, and will never be shared. Name *FirstLastEmail *Phone number *Terms and Conditions *I agree to the Terms and Privacy Policy.NextTell us about yourself Did you know? There are variations in genetic testing based on gender due to certain cancers being specific to women and men. Are you male or female? *MaleFemaleWhen were you born? *PreviousNextTell us about yourself Did you know? Ashkenazi Jewish is a person of Eastern European Jewish descent. Most Jewish people in the United States are of Ashkenazi descent. Are you of Ashkenazi Jewish Heritage? *YesNoI'm not surePreviousNextPersonal History of Cancer These questions are based on the clinical guidelines doctors use to determine whether you should be tested for hereditary cancers. Have you ever been diagnosed with or currently have any type of cancer? *YesNoPlease check all that apply.Breast CancerColon CancerOvarian CancerPancreatic CancerStomach CancerUterine CancerOtherPlease check all that apply.Prostate CancerBrain CancerUrinary Tract CancerRenal (Kidney) CancerPelvic CancerGallbladder (Biliary Tract) CancerSmall Bowel CancerSebaceous AdenomaNone on this listHave you previously taken a molecular genetic cancer screening test?YesNoI'm not surePreviousNextFamily's History of Cancer Close relatives are limited to the following: parents, grandparents, great-grandparents, and siblings. Do you have any close relatives currently or previously diagnosed with any type of cancer? *YesNoWhich of the following cancers have your close relatives been diagnosed with? (Please check all that apply) *Breast CancerColon CancerOvarian CancerPancreatic CancerStomach CancerUterine CancerOtherPlease check all that apply. *Prostate CancerBrain CancerUrinary Tract CancerRenal (Kidney) CancerPelvic CancerGallbladder (Biliary Tract) CancerSmall Bowel CancerSebaceous AdenomaNone on this listPreviousNextEligibility & Coverage We coordinate everything directly with your doctor and health insurance provider to ensure the entire process is made simple. Do you have health insurance? *YesNoWhat type of health insurance do you have? Many health insurances cover genetic testing at little to no out-of-pocket cost. *Select onePrivateMedicareMedicare AdvantageMedicaidTricareWho's your primary insurance carrier? *Select oneAetnaBlue Cross Blue ShieldCignaHumanaUnited HealthcareSelf PayOtherWho's your health insurance provider? *PreviousNextEligibility & Coverage We coordinate everything directly with your doctor and health insurance provider to ensure the entire process is made simple. Do you have a primary care physician? The information you've submitted must be reviewed and ordered by your primary healthcare provider. *YesNoWho's your primary care physician?Where is your primary care physician located? PreviousNextPatient Consent & Delivery Almost done! Let us know where to send your kit and sign the patient consent form for the NGS Hereditary Cancer Panels. Delivery Information. Let us know where you would like your NGS Cancer Screening kit sent to. (Optional)When is the best time to reach you by phone? One of our representatives will need to contact you to verify the informative you have submitted. *Select TimeMorningEarly AfternoonAfternoonEveningPatience Opt-in: *I give Incaremd medical staff permission to follow up and ask medical questions, insurance information to share with clinical laboratory so that the test and that the provider consultant may be covered by patient listed health insurance, therefore reducing or eliminating their out of pocket expense. Acknowledge: * I acknowledge that the doctor who provides me with my test results is not replacing or substituting any medical treatment or plan that has been or will be provided by my primary care physician or any specialist. I know that this information is being providing for my personal knowledge and it is my choice if I choose to share it with my current or future doctors or specialists based on the outcome of the results and my consultation.PreviousNameSubmit
