Analysis Form

Please fill the form below to send a sample to Physiotarget:

To download the Patient Consent Term, please, click here


    Physician Information







    Patient Information





    Specimen Information









    Patient Information










    Analysis Type
    (required)



    Histopathological report









    Staging




    Neoadjuvant Treatment







    Adjuvant Treatment







    Signed Consent Term



    Note: A digital signature is automatically generated when sending data by clicking on the “Send” button.
    This digital signature is sent to the physician’s email and must be associated with the specimen when mailing it for proper sample tracing.