EN-ISO 15198:2012
RequestNo:
Request date:
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
Packaging Instruction 650 (PI650) applied to UN3373: http://www.en.bvfplatform.nl/home.html and http://www.postnl.nl/zakelijk/klantenservice/English/.
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