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TESTS ORDERED FOR
Last Name
First Name
Middle Initial
DOB MM/DD/YY
Sex
M
Address
City
Fasting _____ hrs
Non-Fasting
State
Standing Order Frequency: __________ per
week /
Zip
month /
Phone
Email
Valid until MM/DD/YY
year
F
Cash Pay
REQUIRED ICD-9/ICD-10 code(s):
TESTS ORDERED BY
Clinician Name
NPI
Email
Address
City
State
Zip
Phone
Copy To
Fax
Clinician Signature
Fax
Date MM/DD/YY
x
COMMON PANELS All tests available on an individual basis.
Panel components listed on reverse.
BMP – Basic Metabolic Panel
CBC, no Diff
CBC w/ Auto Diff
CMP – Comprehensive Metabolic Panel
Electrolytes Panel
Hepatic Function Panel
Hepatitis Panel, Acute with reflex
to HBsAg confirmation
Reflex to HBsAg confirmation
Reflex to HepC, RNA Quant
Lipid Panel
Obstetric Panel with reflex to confirmation
Reflex to HBsAg confirmation
Reflex to RPR confirmation
Reflex to TP-PA confirmation
Renal Function Panel
80048
$5.76
85027
$4.41
85025
$5.29
80053
$7.19
80051
$4.78
80076
$5.56
80074
$31.58
87341
$7.03
87522
$29.15
80061
$9.11
80055
$30.07
87341
$7.03
86592
$2.91
86780
$9.01
80069
$5.91
REPRODUCTIVE HEALTH
DHEA-S
Estradiol
Follicle Stimulating Hormone (FSH)
hCG – (Maternal), Blood Quantitative
Luteinizing Hormone (LH)
Progesterone
Prolactin
Sex Hormone Binding Globulin (SHBG)
Testosterone, Free
Testosterone, Total
82627
$15.13
82670
$19.01
83001
$12.65
84702
$10.25
83002
$12.60
84144
$14.20
84146
$13.19
84270
$14.79
84402
$17.33
84403
$17.57
STI
Chlamydia Trachomatis, DNA Qualitative
87491
Hepatitis B Surface Antigen (HBsAg) with reflex
87340
to confirmation
87341
Reflex to HBsAg confirmation
Herpes Simplex 2 (HSV2), IgG
86696
HIV screen with reflex to confirmation
87389
Reflex to HIV-1/HIV-2 Ab Diff conf
multiple
Reflex to HIV-1 RNA Quant conf
87536
N. Gonorrhea, DNA Qualitative
87591
Syphilis screen with reflex to confirmation
86780
Reflex to RPR confirmation
86592
Reflex to TP-PA confirmation
86780
$12.06
$7.03
$7.03
$13.17
$16.39
$15.25
$57.90
$12.06
$9.01
$2.91
$9.01
ALPHABETICAL TESTS (H–Z)
THYROID
T3, Free – Triiodothyronine, Free
T3, Reverse – Triiodothyronine, Reverse
T3, Total – Triiodothyronine, Total
T4, Free – Thyroxine, Free
T4, Total – Thyroxine, Total
Thyroglobulin Antibodies
Thyroid Peroxidase Antibody (TPO)
Thyroid Stimulating Hormone (TSH)
Reflex to T4 free
Thyroid Uptake
84481
$11.53
84482
$10.73
84480
$9.65
84439
$6.14
84436
$4.68
86800
$10.83
86376
$9.90
84443
$11.44
84439
$6.14
84479
$4.41
URINE
Microalbumin, Urine
Microalbumin/Creatinine Urine Random
Urinalysis, Complete
Reflex to culture & susceptibility
82043
$3.94
multiple
$7.46
81001
$2.16
87086
$5.50
(Additional tests may be performed and charges incurred if urine culture tests positive.)
ALPHABETICAL TESTS (A–H)
ABO/RhD Blood Typing
Amylase
Antinuclear Antibodies (ANA) Screen with
reflex to confirmation
Reflex to ANA confirmation
Cortisol, Total
C-Reactive Protein (CRP)
C-Reactive Protein, High Sensitivity (hsCRP)
Creatine Kinase
Deamidated Gliadin Peptide (DGP) Ab, IgA
Deamidated Gliadin Peptide (DGP) Ab, IgG
EBV Early D Antigen (EA-D), IgG
EBV Nuclear Antibody, IgG
EBV Viral Capsid Antigen (VCA) - IgG
EBV Viral Capsid Antigen (VCA) - IgM
Erythrocyte Sedimentation Rate (ESR/Sed Rate)
Ferritin
Folate
Gamma-Glutamyltransferase (GGT)
Glucose
Glucose Tolerance Test (GTT), 3hr, 100g
Helicobacter Pylori, IgG
Hemoglobin A1c (HbA1c)
Hepatitis B Surface Antibody (HBsAb)
Hepatitis C Antibody Screen
Reflex to HepC, RNA Quant
multiple
$4.06
82150
$4.41
86038
$8.23
86039
$7.60
82533
$11.10
86140
$3.52
86141
$8.81
82550
$4.43
83516
$7.85
83516
$7.85
86663
$8.93
86664
$10.41
86665
$12.35
86665
$12.35
85652
$1.84
82728
$9.27
82746
$10.01
82977
$4.90
82947
$2.67
multiple
$11.43
86677
$9.87
83036
$6.61
86706
$7.31
Visit theranos.com for complete test menu and pricing.
Limited Medicare coverage based on diagnosis and frequency rules.
Ordered reflex tests only performed when medically appropriate. For any payer with a medical necessity requirement (including
Medicare and Medicaid), physicians should only order those tests that are medically necessary for diagnosis and treatment.
86803
$9.71
87522
$29.15
Herpes Simplex 1 (HSV1), IgG
Homocysteine
IgA
Insulin
Iron
Iron and TIBC
Lactate Dehydrogenase
Lipase
Magnesium
Parathyroid Hormone (PTH), Intact
Partial Thromboplastin Time (PTT)
Phosphorus, Inorganic
Prothrombin Time (PT/INR)
PSA, Free
PSA, Total
Rheumatoid Factor, Total
Tissue Transglutaminase (tTG) Antibody, IgA
Tissue Transglutaminase (tTG) Antibody, IgG
Uric Acid
Varicella-Zoster Antibody
Vitamin B-12
Vitamin D 25-OH
86695
$8.98
83090
$11.48
82784
$6.33
83525
$7.78
83540
$4.41
multiple
$10.36
83615
$4.11
83690
$4.69
83735
$4.56
83970
$28.09
85730
$4.09
84100
$3.23
85610
$2.68
84154
$12.52
84153
$12.52
86431
$3.86
83516
$7.85
83516
$7.85
84550
$3.08
86787
$8.77
82607
$10.26
82306
$20.15
OTHER TESTS/REQUESTED REFLEX TESTS/NOTES:
Sample Collection Date/Time
GEN 3.1
panel components
All tests available on an individual basis.
A complete list of tests, descriptions, and prices can be found at theranos.com or on the Theranos app.
Basic Metabolic Panel (BMP)
Blood Urea Nitrogen (BUN) • Calcium Total • Carbon dioxide • Chloride • Creatinine • Glucose • Potassium • Sodium
Complete Blood Count (CBC)
Hematocrit • Hemoglobin • MCH • MCHC • MCV • Platelets • RBC • RDW • WBC
Comprehensive Metabolic Panel (CMP)
Alanine Aminotransferase (ALT) • Albumin • Alkaline Phosphatase (ALP) • Aspartate Aminotransferase (AST) • Bilirubin Total • Blood Urea Nitrogen (BUN) • Calcium Total • Carbon dioxide • Chloride •
Creatinine • Glucose • Potassium • Protein Total • Sodium
Electrolytes Panel
Carbon dioxide • Chloride • Potassium • Sodium
Hepatic Function Panel
Alanine Aminotransferase (ALT) • Albumin • Alkaline Phosphatase (ALP) • Aspartate Aminotransferase (AST) • Bilirubin Direct • Bilirubin Total • Protein Total
Hepatitis Panel, Acute with reflex to HBsAg confirmation*
Hepatitis A Antibody, IgM • Hepatitis B Core Antibody (HBcAb), IgM • Hepatitis B Surface Antigen (HBsAg) with reflex to HBsAg confirmation (+$7.03)* • Hepatitis C Antibody Screen
Lipid Panel
Cholesterol • High-density Lipoprotein (HDL) • Low-density Lipoprotein (LDL) • Triglycerides
Obstetric Panel with reflex to confirmation*
ABO/Rhd Blood Type, Antibody Detection, RBC, CBC with Auto Diff, WBC • Hepatitis B Surface Antigen (HBsAg) with reflex to HBsAg confirmatory (+$7.03)* •
Rubella Antibody, IgG • Syphilis screen with reflex to confirmation (Treponema Pallidum IgG with reflex to RPR (+$2.91)* with reflex to TP-PA (+$9.01)*
Renal Function Panel
Albumin • Blood Urea Nitrogen (BUN) • Calcium Total • Carbon dioxide • Chloride • Creatinine • Glucose • Phosphorus, Inorganic • Potassium • Sodium
Save time by uploading your lab order prior to your theranos visit.
Create a Theranos Account.
Download the Theranos app from the App Store or Google Play store or go to www.theranos.com to sign up.
Upload paper lab orders in the Theranos app.
Take a photo using your Theranos app.
Complete this order at a Theranos Wellness Center™.
Find a Theranos Wellness Center™ near you using the app or theranos.com/centers.
= Fasting recommended.
*Ordered reflex tests only performed when medically appropriate. Additional charges apply if reflex is performed.
Lab services provided by Theranos, Inc., a CLIA-certified laboratory. Theranos is an independently owned and operated company.