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Genetics Lab Request Form Mobile App

The Genetics Lab Request Form mobile app allows physicians and clinics to request genetic testing using a smartphone or tablet. The app records the following: Patient Information, Referring Physician, Genetic Counselor/Care Coordinator, Billing Information, Sample Information, Clinical Indications for Study, CytogeneticTest Menu and Molecular Test Menu. This app can be made HIPAA Compliant. While collecting data using GoCanvas, saving the current state is fairly simple - simply select the "Save" button on the main menu.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name

  • Ico textbox

    Medical Record#

  • Ico dropdown

    Sex

  • Ico date

    DOB

  • Ico textbox

    SS#

  • Ico multiline

    Address:

  • Ico textbox

    Phone#

  • Ico textbox

    Name

  • Ico textbox

    Institution

  • Ico textbox

    NPI#

  • Ico multiline

    Address

  • Ico textbox

    Phone#

  • Ico textbox

    Fax#

  • Ico statictext

    CC report copies to:

  • Ico textbox

    Name

  • Ico textbox

    Institution

  • Ico textbox

    Fax#

  • Ico textbox

    Name

  • Ico textbox

    Phone#

  • Ico textbox

    Fax#

  • Ico checkbox

    Bill patient (Please attach copy of insurance card)

  • Ico textbox

    Name of insured

  • Ico date

    DOB

  • Ico textbox

    SS#

  • Ico textbox

    Relationship to Patient

  • Ico textbox

    Phone#

  • Ico checkbox

    Bill physician office or laboratory

  • Ico textbox

    Institution/Organization

  • ...and More!

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