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Consent for Use
of Electronic Signature
I, ___________________________________________________, authorize the use of my electronic signature
[ Physician Name ]
on all clonoSEQ® test orders.
Physician Name:
Date:
Note to Physician: Please provide your signature within the box below. Adaptive Biotechnologies will scan
and upload your signature to all future clonoSEQ Test Requisition Forms. Your signature will not be used
for any other purpose without your consent.
Physician Signature:
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