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Patients & Family

Please complete all of the following information. After completing this questionnaire, please print, sign and fax to Fujirebio Diagnostics at 610.240.3912. After fax receipt, you will be sent a package containing Patient Information Brochures and a Test Requisition Form.

Ordering Physician Contact Information:

All fields are required except email address.

Physician Name: First:
Last:
Physician Specialty: Specialty:
Office Address: Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Office Contact:

Ofice Telephone Number:

Office Fax Number:


Email Address:

Type of location where samples will be drawn:





Check your responses to the statements below:

1. Physician has read and understands HUD information provided.

2. Physician agrees to comply with FDA-approved device labeling.

3. Physician agrees to comply with pertinent state and federal regulations.

4. Physician agrees to comply with national IRB requirements.

5. Physician acknowledges that HUDs are subject to the Medical Device Reporting (MDR) regulation and will notify Fujirebio Diagnostics of any unanticipated adverse device effect.

6. Physician, to the best of their ability, will protect the rights, safety, and welfare of the patient for whom MESOMARK is ordered.

Yes, please keep me informed about MESOMARK® and other information from Fujirebio Diagnostics, Inc.

 

06/01/20

 

   

 

If you have questions about the questionnaire or are having trouble with the form, please email us at mesomark@fdi.com or call us at 1-800-342-9225.