Order Form for Clinical WGS

Patient Order Form for Clinical Whole Genome Sequencing

This form is for submitting a clinical WGS order with Jura Health. If you are a clinician and haven't registered with us before, please complete that form first at: jura.health/hcp-registration.
Ordering Healthcare Provider (HCP)

Please include your Institution to ensure we associate the order with the proper HCP account.
HCP Name

First NameLast Name
Institution
Patient Information
Patient Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has the patient already registered with Jura Health?
- Please include the name of the patient or parent/guardian and an email for registration. We will send them a link to our patient registration form.
  
  You can also share the registration form directly with patients at: http://jura.health/patient-registration
- Patient or Guardian
  
  First NameLast Name
- Email of the Patient or Guardian
- Phone of the Patient or Guardian
  Please enter a valid phone number.Format: (000) 000-0000.
- Order Type
- Please select the type of testing you would like for your patient. The standard and easiest method is Proband, which tests only the individual. Duo and Trio test the individual but also gather genetic information from one or two relatives. These tests are more comprehensive but add the complexity of documenting and sampling from those relatives. If you choose duo or trio we will reach out to discuss the details of who will be sampled.
- Type
- Clinical Coding
- Even though you may have included ICD-10 codes in the clinical records attached below, please state ALL clinically relevant codes.
- ICD-10 Codes
  Add any applicable codes
- The Human Phenotype Ontology (HPO) provides a standardized vocabulary of phenotypic abnormalities encountered in human disease. You can learn more here.
- HPO Terms
  Add any available
- Clinical Information
- Please take this section seriously. Accurate testing requires a thorough understanding of the patient’s clinical condition and relevant medical history. Additionally, a prior authorization is required for reimbursement and these answers impacts our ability to gain reimbursed by Medicaid and/or other payors. Without reimbursement the test will not proceed.
- Indication for Testing (brief summary)
  
  0/300
- Statement of Medical Necessity
  
  Please include examples like: impacts to future treatment, any known suspected heritable traits, impact over other diagnostic tools. Include any links to references such as: https://doi.org/10.1542/peds.2025-0722190/2000
- Clinical History
  
  0/2000
- Family History
  
  0/2000
- Previous Genetic Results
  Add any previous genetic test findings
- Medical History Documents
  
  Please attach any relevant medical history documents and/or previous diagnostic testing results.
  Cancelof
- Choose an Option
- Genomic Testing Specific Questions
  
  These questions can help gain better results especially when comparing genomes of family members. In many cases the background information may be unknown.
- Is the patient adopted?
- Was the patient conceived via an egg donation?
- Was the patient conceived via sperm donation?
- Has the patient ever undergone an allogeneic transplant?
- Has the patient received a blood transfusion in the 4 weeks prior to sample collection?
- Does the patient have a currently known hematological malignancy?
- Is there a known relatedness between the biological parents (consanguinity)?
- I hereby attest that my typed name below constitutes my legally binding electronic signature. By signing I acknowledge that I am authorized under applicable law to order this test for this patient as or for the clinician listed above.
  Type your full name
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Should be Empty:

Patient Order Form for Clinical Whole Genome Sequencing

Ordering Healthcare Provider (HCP)

Patient Information

Order Type

Clinical Coding

Clinical Information

Genomic Testing Specific Questions