ASPER WELLNESS SAMPLE SUBMISSION FORM
ORDERING PERSON AND REPORTING INFORMATION / ADDITIONAL REPORTING INFORMATION(if applicable)
Name
(first name,
last name)
Institution
Address
Phone
Results delivery / by e-mail by regular mail
Sample receipt confirmation / Person
BILLING INFORMATION
By submitting DNA samples to Asper Biogene the client agrees that invoices shall be paid within 10 calendar days as of the invoice date and in case of delay in the payment, the open invoice amounts will accrue interest amounting to 0,1 % per calendar day.
Contact person
Institution
Address
Phone
VAT account number
In EU countries please add paying institution's VAT account number, otherwise 20% of VAT tax will be added to the invoice.
PO number
Invoice delivery / by e-mail by regular mail
Patient’s data needed for invoicing / yes no
SAMPLE INFORMATION
Type / whole blood in EDTA DNA Other......
Date of collection
PATIENT INFORMATION
Name
Date of birth
Sex
Ethnic origin
Clinical diagnosis
TESTS REQUIRED
Age-related Macular Degeneration /
Targeted mutation analysis
NGS panel of genes*
Single mutationAlzheimer Disease, Recovery from Traumatic Brain Injury,
Coronary Heart Disease /
Targeted mutation analysis
Athletic Performance /Targeted mutation analysis
Celiac Disease /Targeted mutation analysis
Lactose Intolerance /Targeted mutation analysis
Thrombophilia / Targeted mutation analysis* Clinical interpretation is not available
Service includes
DNA extraction
Genotyping
Confirmation of disease associated variants by Sanger sequencing
Interpretation
The results report by registered mail
Targeted mutation analysesresults will be delivered by 2-4 weeks
NGS-based test results will be delivered by 6-9 weeks
PATIENT’S CLINICAL INFORMATION
Reason for referral
confirmation of clinical diagnosispresymptomatic testingrisk assessment
Age at the onset of symptoms…………......
anemia
weight loss
muscle atrophy
gastrointestinal findings……………………………………………………………………………………………………….....
......
other findings………………………………………………………………………………………………………......
Results of the serological analyses (if applicable):
Anti-tissue transglutaminase antibody IgA (tTG IgA)………………………………………………………...U/ml
Anti-tissue transglutaminase antibodyIgG (tTG IgG)………………………………………………………..U/ml
Anti-endomysial antibody IgA (EMA IgA)……………………………………………………………………...U/ml
Deamidated gliadin peptide antibody IgA (DGP IgA)………………………………………………………...U/ml
Deamidated gliadin peptide antibody IgG (DGP IgG)………………………………………………………..U/ml
Venous thrombosis (VT)
idiopathic VT
recurrent VT
life-threatening VT(pulmonary embolus, cerebral vein thrombosis etc)
at an unusual site (cerebral, mesenteric, portal, hepatic)
while on oral contraceptives/ hormone replacement / methotrexate therapy
pregnancy and postpartum period associated VT
recurrent fetal loss ( 2nd and 3rd trimester)
Arterial thrombosis
stroke
myocardial infarction
Previous genetic testing
not done
results:
......
......
Family history
unknown
diagnosis…………………………………………………………………………………………………………......
specify the relation to the proband………………………………………………………………………………......
Authorization to use remaining sample material and test results
Asper Biogene may use de-identified (without personal identifying information) remaining sample material and test results for quality improvements and/or scientific purposes.
I give my consent to use my de-identified sample material and test results as described above
I do not give my consent to use my de-identified sample material and test results as described above
Name of patient………………………………………………………………………………………………………………………
Patient’s signature……………………………………………………………………………………………………………………
Date……………………………………………………………………………………………………………………………………
Important:By sending samples and placing an order customer accepts Terms and Conditions and Privacy Policy of Asper Biogene (see website for details).
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ASPER BIOGENE LLC • reg Nº 14265334 • Vaksali 17A, 50410 Tartu, Estonia
phone +372 7307 295 • fax +372 7307 298 • •