New Client Intake Form

Practice Information

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Ordering Physician(s) Information

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Physician Acknowledgement

I understand that as a policy, Arbor Diagnostics provides convenient options for clients and assists in the best patient care possible. Arbor Diagnostics offers custom panel options to all of their physicians. This panel allows each physician to create a testing panel that fits directly with their treatment plans. Besides requesting my custom panel, I can also order any combination of indicidual tests. I certify that the tests ordered are medically necessary. I agree to contact Arbor Diagnostics immediately if my custom panel does not adequately reflect my patient's needs. I may modify my custom panel at any time if needed.

I understand and agree to the statement above. I authorize Arbor Diagnostics to perform the custom panel that I have designated on this form, as I authorize it for my patients and their order forms. At any time, I can modify my custom panel by contacting Arbor Diagnostics and may also order indicidual tests on any specimen.

I understand and agree to the Physician Acknowledgment and Authorization Statement above.