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Traumatic Brain Injury Blood Biomarker Test Order Form

Fields marked with an asterisk are required.

Patient information

Collect the core identity information required to match or create the patient record.

Injury Detail

If 'Other' was selected above, please briefly describe the cause of injury.

If 'Other' was selected above, please briefly describe the type of injury.

Briefly describe your symptoms

I hereby authorize and provide my informed consent for the collection of blood samples by a trained phlebotomist or qualified healthcare professional as ordered by my physician. Furthermore, I understand that my physician may order specific genetic testing as part of my diagnostic evaluation. By signing below, I acknowledge that I have been informed of the purpose of these tests and voluntarily consent to both the clinical blood draw and the subsequent genetic analysis.

By submitting this form, you confirm the information is accurate to the best of your knowledge.