What information do I need to provide on the test requisition form?

The Requisition shall include the patient’s name, date of birth, gender, medical record number, Specimen collection date, ordering physician’s first and last name, treating physician’s first and last name, initial pathology diagnosis confirming Barrett’s Esophagus and stage (non-dysplastic, indefinite for dysplasia or low grade dysplasia), unique number or code assigned to the Specimen that is the subject of the Requisition.