Page 40 - MyOwnSkin-Hensler 6_2020

Physician Orders for MyOwn Skin™

Orders to BioLab Sciences, Inc.:
First Init First 5 Letters 2 Digit
Facility or Office____________________________________________ Patient ID: First Name Last Name (or X) Year of Birth
Return Address for Shipping MyOwn Skin™: Billing Address for MyOwn Skin™: same other
_________________________________________________________ _____________________________________________________
_________________________________________________________ _____________________________________________________
_________________________________________________________ _____________________________________________________

Samples supplied to BioLab Sciences, Inc. by Physician:
_____ Samples of Blood from Patient Time and Date Explant was placed in container:
_____ Samples of Skin from Patient (Explant) _____________________________________________________

Services Ordered: Please Mark Intended Placement of
MyOwn Skin™
Process the enclosed skin samples and blood samples into:

_____ One (1) 5cm x 5cm patch of MyOwn Skin™ (25cm²)
_____ Two (2) 5cm x 5cm patches of MyOwn Skin™ (50cm²)
_____ One (1) 10cm x 10cm patch of MyOwn Skin™(100cm²)

(Check All that Apply) _____ Two (2) 10cm x 10cm patches of MyOwn Skin™(200cm²)

_____ Three (3) 10cm x 10cm patches of MyOwn Skin™(300cm²)
Front Back
_____ Other __________________________________________
(note: over 300cm² requires added blood)
Is Case Bilateral? Yes No
and return to Facility via expedited courier upon completion. Notify Facility via email and phone to schedule return shipment.
(email address: _________________________________________phone__________________________________)

Expected Date _____________________________ and Time ___________________ of surgical application of MyOwn Skin™

Notes: _____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

______ (Initial) I certify that the Patient has executed an informed consent regarding this procedure.

Ordered by: ___________________________________ ____________________________________________________
Provider Name Provider Signature Date

TM
Acknowledgement Agreement for the request and use of MyOwn Skin

I understand that by making this request to process MyOwnSkin TM (MOS) on my, or my patient's behalf, I will abide 100% by the process protocol described by
BioLab Sciences for the production of MOS. I understand that I am fully responsible and liable if I make any changes that deviate from the production process
protocol.
• All biological components must be received at BioLab Sciences facilities within 22 hours of sample and blood collection. Collection time and date must
be provided on the order form.
• All blood collection tubes must be filled completely and sealed to prevent leakage.
• A patient ID must be provided on the order form. ALL SAMPLES MUST BE DE-IDENTIFIED and HIPAA compliant. Use the following format for patient
ID: First Init First Name/First 5 Letters of Last Name/2 Digit Year of Birth. If no letter, use X. i.e. – JDOEXX75 or BSMITH52
• All biologics must be labeled with the patient ID.
• All applicable forms must be completed and accompany the tissue to BioLab Sciences.
• The standard application date is 9 days from collection. If the application date exceeds the standard 9 days, the facility may be asked to provide more
biologics to extend the process. However, this will not guarantee that MOS will be ready and viable beyond the initial application date.
• I understand that MOS contains living cells and its production is not guaranteed 100%. By submitting this request, I understand that there is a very
small probability that BioLab Sciences may not be able to process my request.

By signing this document, I acknowledge that I am fully responsible for the collection process described by BioLab Sciences and am faithfully following all of
its instructions to successfully produce MOS.

Signed and acknowledged: ___________________________________ ____________________________________________________
Provider Name Provider Signature Date
V1.7 DIST ID_________________