EN-ISO 15198:2012
Print and include this form when sending the patients sample

Patient Information

Ordering Physician Information

Test Requested – Indication

Reason for testing

Reason for testing
Expedited testing required?

Sample details

Reason for testing

Clinical Information

Clinical findings
Have any relatives previously had genetic testing?
*** Draw the pedigree, provided on this form.

Cost overview

Test
Quantity
Price
Total cost

Acceptance of financial responsibility for genetic testing

My signature indicates that I accept financial responsibility for all fees associated with this genetic testing order.






Date






Signature of responsible party






Printed name of responsible party

Pedigree

Indicate patient with arrow
Indicate carriers with
Indicate affected people with
Sending
Do not freeze the samples. Send at room temperature. EC countries: from Monday to Wednesday by regular post, after Wednesday send by express.
Send prenatal material on the same day with a courier. Non EC countries: Send with a courier.
Packaging Requirements for Sample Transportation
Necessary equipment: primary Leak-proof receptacle, absorbent material, safety bag, outer packaging. (For Belgium: http://www.bvfplatform.nl)
For your convenience, cut and use as address label:
AGDx Laboratory Genome Diagnostics (H01-114)*
Amsterdam UMC
Meibergdreef 9
1105 AZ AMSTERDAM
The Netherlands
MEDICAL DIAGNOSTIC SAMPLE
URGENT SHIPPING!
*Outside office hours: delivery at LAKC B1-114