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Requisition

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.: 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 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. 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
Requester

Invoice to (if different from above)

Patient information

CPR (Denmark only)

Material
DNA conc. ng/µL


Ship sample to
Amplexa Genetics A/S

Sverigesgade 24, st.
DK-5000 Odense C
Denmark
IMPORTANT: This requisition must accompany the sample.
Supplemental information







* 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