Application Form - genetic tests for underrepresented countries
Applicant Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Institution
*
Test requirements and information:
1. Who requests the test? (Mark all that apply.)
Physician
Patient
Relative
2. Disorder:
*
Please Select
Suspected
Diagnosed
3. Are there other family members who have been affected by the same or a similar condition as index patient (if yes, please provide more details in the box below):
*
Please Select
Yes
No
Further information on other family members who have been affected by same/similar condition before:
4. What is the requested test?
*
NGS-based sequencing (e.g. panel/whole-exome)
Sanger-sequencing (targeted familial variant testing)
5. If the test is time-sensitive, please provide the details for this.
6. How many samples should be tested?
*
7. Who shall be tested? (Mark all that apply.)
*
Index patient
Parent(s)
Affected sibling (s)
8. Are there previous genetic results? (If yes, provide more details below)
*
Please Select
Yes
No
More details on previous genetic results:
9. Please provide reason of why funding from local sources is not available
*
Submit
Should be Empty: