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Submitted URL: http://www.invitae.com/pio/requisition-billing
Effective URL: https://www.invitae.com/us/patients/requisition-billing
Submission: On July 07 via manual from CO — Scanned from DE
Effective URL: https://www.invitae.com/us/patients/requisition-billing
Submission: On July 07 via manual from CO — Scanned from DE
Form analysis
1 forms found in the DOMName: requisition-billing-form — #
<form action="#" data-testid="requisition-billing-form" name="requisition-billing-form">
<div class="row">
<div class="c0233 col-md-6"><label class="c0234" for="rq">ORDER ID</label>
<div class="c0235"><span>RQ</span><input name="rq" class="c0232" data-testid="input-rq" id="rq" type="text" value=""></div>
</div>
<div class="c0233 col-md-6 col-sm-12"><label class="c0234" for="dob">PATIENT DATE OF BIRTH</label>
<div class="DayPickerInput">
<div><input type="text" placeholder="MM/DD/YYYY" class="c0232" data-testid="input-dob" name="dob" value=""><span role="button" tabindex="0"></span></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-12"><button data-testid="submit-requisition-billing-form" disabled="" type="submit" class="btn-teal btn btn-lg btn-default btn-block">Continue</button></div>
</div>
</form>
Text Content
You need to enable JavaScript to run this app. Billing and payment details Confirm VIEW YOUR BILLING AND PAYMENT DETAILS ORDER DETAILS Enter an Order ID and the patient's date of birth to see the billing details. ORDER ID RQ PATIENT DATE OF BIRTH Continue * US * Privacy * Terms * Licensing * Contact © 2024 Invitae Corporation. All rights reserved. * * * *