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theranos support: +1 855 843-7200 fax: +1 650 852-9594 theranos.com 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.