LABORATORY REQUISITION  FORM:

MOLECULAR GENETIC TESTING

REQUISITION/ORDER FORM

An electronic version of the form is sent to the emailed provided under "Requester", print it and included it with your sample.

You can add additional information (e.g. pedigree) on the hard copy if needed.

You can expect a Turn-around Time (TAT) 5-6 weeks 

OBLIGATORY INFORMED CONSENT:
By ordering an analysis at Amplexa Genetics A/S, the requester confirms to have obtained the necessary informed consent for the performance of the requested analyses, and accepts Amplexa Terms and Conditions.

Requested analysis
Name *
   
Requester
Title / Name *
Department
Institution
Address
Postal Code
City
Country
Phone
E-mail *
EAN/Vat no. for Company/Institution
Order no. (optional)
   
Invoice to (if different from above)
Title / Name
Department
Institution
Address
Postal Code
City
Country
Phone
E-mail
EAN/Vat no. for Company/Institution
Order no. (optional)
   
Patient information
Hospital / Patient ID no. **
Date of birth **
 
   CPR (Denmark only)
  
Family name **
First name **
Sex
   
Material
Sample

DNA conc. ng/µL
Date of sampling
Date of shipment
   
Ship sample to
Amplexa Genetics A/S

Tolderlundsvej 3B, 2nd
DK-5000 Odense C
Denmark

IMPORTANT: This requisition must accompany the sample.
   
Supplemental information
Have any family members been tested previously?
       

If YES, previously identified familial mutation(s)


and/or, if relevant, previous AMPLEXA reference number


Please give all relevant information such as: Diagnosis, family history of disease, pedigree, family members previously tested genetically, identified mutations, disease pattern for patient etc.
* Fields are required, ** Required only one of them