Amplexa Genetics A/S

Sverigesgade 24, st.
DK-5000 Odense C,
Denmark

Tel. +45 66 11 66 28
Opening hours: Mon-Fri: 9:00-15:00

Bank Name: Danske Bank
SWIFT: DABADKKK
For payment in DKK:
Reg. nr.: 3596 Account nr.: 3362237343
IBAN: DK1230003362237343
For payment in EURO:
Reg. nr.: 3596 Account nr.: 3600085980
IBAN: DK4030003600085980

LABORATORY REQUISITION FORM: MOLECULAR GENETIC TESTING

REQUISITION/ORDER FORM
An electronic version of the form is sent to the email 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. A hard-copy requisition or an e-mail stating the specific analysis together with the receipt of a sample is considered an order to conduct the analysis.

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
Male Female Not important

Material

Sample

Blood (2-5ml EDTA-blood)

DNA (minimum 3 µg)

DNA conc. ng/µL

Date of sampling *

Date of shipment *

Ship sample to
Amplexa Genetics A/S
Sverigesgade 24, st.
DK-5000 Odense C
Denmark

IMPORTANT: This requisition must accompany the sample.

Supplemental information

Have any family members been tested previously?

Yes No Don't know

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.

I agree with terms and conditions

* Fields are required, ** Required only one of them
Vi gemmer ikke dine personlige data

Betingelser

I de tre nævnte pakker undersøges udelukkende for allerede kendte sygdomsfremkaldende varianter hos testpersonen. Varianterne er omtalt i Human Genome Mutation Database (HGMD) og publiceret i videnskabelige tidsskrifter.

Amplexa Genetics A/S

Sverigesgade 24, st.
DK-5000 Odense C,
Denmark

Tel. +45 66 11 66 28
Opening hours: Mon-Fri: 9:00-15:00

CVR nr. 29428441
info@amplexa.com

Bank Name: Danske Bank
SWIFT: DABADKKK
For payment in DKK:
Reg. nr.: 3596 Account nr.: 36003362237343
IBAN: DK1230003362237343
For payment in EURO:
Reg. nr.: 3596 Account nr.: 3600085980
IBAN: DK4030003600085980