Please place collection kit
barcode here.
1234567-2-X
Empower International Requisition
PLEASE COMPLETE ALL FIELDS IN ENGLISH. REQUISITION FORMS SUBMITTED WITH MISSING INFORMATION MAY CAUSE A DELAY IN RESULTS.
1. PATIENT INFORMATION 2. CLINIC / LABORATORY INFORMATION
Last Name First Name Clinic/Laboratory Name Natera™ LIMS ID
F M
Date of Birth (MM/DD/YY) Sex Assigned at Birth MRN / Third-Party Lab ID Ordering Clinician Name Telephone
( )
Email Address Telephone
Address 3. PAYMENT INFORMATION
Bill Clinic Bill Patient
City Country
Race or ethnicity:
African American/Black Southeast Asian
East Asian White (Non-Hispanic)
South Asian Hispanic/Latin American
Ashkenazi Jewish American Indian or Alaska Native
Other Native Hawaiian or other Pacific Islander
Date of Sample Collection (DD/MM/YY)
4. TEST OPTIONS (REQUIRED) See QR code below for panel descriptions information
1 Must select only one base test below: 2 Add additional panel–select ONE (optional)
BRCA1 & BRCA2 GYN, Guidelines-based (total 19)
For patients meeting hereditary breast and ovarian cancer
syndrome testing criteria AND Multi-Cancer (total 40)
Comprehensive (total 81)
Lynch syndrome (MLH1, MSH2, MSH6, PMS2, EPCAM)
For patients meeting colorectal cancer syndrome testing criteria Breast STAT (10 genes) + Comprehensive (81 genes)
Can only be ordered with the BRCA1/2 base test
Other Panel ID
Please attach your most recent progress/clinical notes or send them to [email protected].
5. PATIENT COMPLETE CANCER HISTORY (include all cancers and age of dx) 6. FAMILY HISTORY OF CANCER
Check this box if the patient does not have a history of cancer or current diagnosis No known family history
of cancer (if no cancer please complete the family history of cancer section)
Limited family structure: Adopted or less than two 1st/2nd degree relatives living past age 45 years old
Patient has had genetic testing for hereditary cancer (If yes, please attach the report)
Cancer/Tumor Age at Dx Relationship Maternal or Paternal Cancer site(s) Age at Dx Relative Deceased
Breast DCIS Triple negative (ER-, PR-, HER2-)
Invasive Ductal High-Risk HER2-**
Invasive Lobular Metastatic
Ovarian Non-epithelial
Prostate Metastatic Intraductal/Cribriform
Pancreatic
Endometrial/Uterine
Colon/Rectal
Stomach Additional information
Hematologic malignancy (Leukemia/Lymphoma)
Active No Evidence of Disease
Other cancer(s): Type
Additional information
Colon Polyps: Number of polyps
If tumor screening was performed, select all that apply: Known Familial Mutation: Gene: __________ Variant: _____________
MSI high? If yes, cancer type tested
Mismatch Repair (MMR) proteins absent on IHC? Result Relationship __________________ Report available? Yes (please attach) No
** See NCCN.org for the definition of high-risk disease
7. CONTRAINDICATIONS FOR EMPOWER TESTING
Patients with a history of allogenic bone marrow transplant, active hematologic malignancy, or minors without medical necessity for testing
8. SAMPLE PROCESSING AUTHORIZATION
Ordering Clinic / Laboratory confirms that the patient has given informed consent(s) to the following processing activities:
Patient’s samples and related data will be sent outside of the country of origin for performance of the ordered test(s) by Natera and/or its contractor(s), (2) patient
and patient’s heirs will not receive any payments, benefits, or rights to any resulting products or discoveries, and (3) to the extent the patient has selected self-pay,
that Natera and its contractor(s) may use the patient information provided on this form to contact the patient directly regarding billing and payment.
Patient’s leftover samples and related data may be kept by Natera in compliance with applicable laws, for purposes of future research & development, product
validation and quality assurance, either independently or in collaboration with third‑party partners.
Signed by:
Authorized Signature (REQUIRED)
For the full list of genes in each Empower test, visit
https://www.natera.com/empower-for-clinicians/
HCT 1 FOR-0022004 Empower ROW Requisition Form Rev02 Please see second page
9. FAMILY TESTING PROGRAM
Natera Family Testing Program: Blood relatives of individual with a positive Empower test are eligible. Only check this box if this information is provided.
Learn more at: natera.com/empower
• Attach a copy of the relative’s positive Empower report or provide their Natera Case ID
Patient’s relationship to the positive relative • Order must be received within 90 days of original report date
Family Member Natera Case ID • Panel to be the same size or smaller compared to previous relative’s test order
10. BREAST CANCER RISK MODEL INFORMATION (For female patients without a personal history of breast cancer)
1. Height ft in 2. Weight lbs 3. Has the patient had children? Yes No How old was the patient when they gave birth to their first child?
4. Approximate age at first menstrual period? 5. Has the patient gone through menopause? Yes No Ongoing If yes, at approximately what age?
6. Ashkenazi Jewish descent? Yes No 7. Has the patient ever used hormone replacement therapy? Yes No Ongoing Start date: End date:
If yes, what type? Estrogen Estrogen + Progesterone I don’t know
8. Number of relatives: Sisters: Daughters: Maternal aunts: Paternal aunts: Maternal half-sisters: Paternal half-sisters:
9. Has the patient ever had a breast biopsy? Yes No/No proliferative diseases If yes, what was the result? Hyperplasia (no atypia) Atypical hyperplasia LCIS Don’t know
10. Has the patient had breast density assessed by mammogram? Yes No Unknown
If known, complete ONE of the following: VAS percentage density ______-______% Volpara volumetric density _____-_____%
BI-RADS ATLAS density: Fatty Average Heterogeneously dense Extremely dense Unknown
For the full list of genes in each Empower test, visit
https://www.natera.com/empower-for-clinicians/
Natera, Inc. | 201 Industrial Road, Suite 410 | San Carlos, CA 94070 | +1 650.249.9090
