Exam request
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Patient information
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Patient ID (CPF)
Patient name
Patient date of birth
Patient biological sex
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Male
Female
Doctor information
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Responsible doctor
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Sarah Mitchell
Doctor's license (CRM)
Doctor's state
UF
Acre
Alagoas
Amapá
Amazonas
Bahia
Ceará
Distrito Federal
Espirito Santo
Goiás
Maranhão
Mato Grosso do Sul
Mato Grosso
Minas Gerais
Pará
Paraíba
Paraná
Pernambuco
Piauí
Rio de Janeiro
Rio Grande do Norte
Rio Grande do Sul
Rondônia
Roraima
Santa Catarina
São Paulo
Sergipe
Tocantins
Doctor's e-mail
Phone (area code + 9 digits)
Tumor type
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Lung cancer
Gastric/GEJ cancer
Urothelial cancer (renal pelvis, ureters, bladder, urethra)
Head and neck cancer
Esophageal cancer
Breast cancer
Cervical cancer
Select the tumor histology
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Non-small cell lung cancer - Squamous (epidermoid)
Non-small cell lung cancer - Non-squamous (Adenocarcinoma)
Treatment line
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Before starting the first metastatic line
Before starting the second metastatic line
Other lines
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Tests
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PD-L1
EGFR
ALK
Select the tumor histology
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Gastric/GEJ cancer of ADENOCARCINOMA type
Treatment line
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Before starting the first metastatic line
Before starting the second metastatic line
Before starting the third metastatic line
Other lines
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Tests
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PD-L1
EGFR
ALK
Select the tumor histology
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Urothelial carcinoma
Treatment line
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Before starting the first metastatic line
Tests
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PD-L1
EGFR
ALK
Select the tumor histology
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Head and neck cancer - Squamous
Treatment line
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Before starting the first metastatic line
Tests
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PD-L1
EGFR
ALK
Select the tumor histology
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Adenocarcinoma
Squamous carcinoma
Treatment line
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Before starting the first metastatic line
Before starting the second metastatic line
Before starting the third metastatic line
Other lines
Could not inform
Tests
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PD-L1
EGFR
ALK
Select the tumor histology
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Triple Negative locally recurrent unresectable or metastatic (TNBC)
Treatment line
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Before starting the first metastatic line
Tests
All fields are required
PD-L1
EGFR
ALK
Select the tumor histology
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Cervical cancer
Treatment line
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Before starting the first metastatic line
Tests
All fields are required
PD-L1
EGFR
ALK
Biopsy location
Biopsy location (hospital/clinic/address)
Does it need collection?
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Yes
No, sample available at the testing laboratory
Clinic
Accredited laboratory
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FLEURY MEDICINA E SAÚDE
Clinic name
Tax ID (CNPJ)
ZIP code
State
State
SP
MG
City
City
SÃO PAULO
City2
Street name
Number
District
Complement (optional)
Phone
Mobile (area code + 9 digits)
Contact name
Secondary e-mail
Accredited laboratory for sample shipping
Accredited laboratory
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FLEURY MEDICINA E SAUDE
Scheduling preference
Scheduling preference
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I want to be contacted for scheduling
Expected collection date
Expected date
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