Test Requisition And Patient Information
ADVERTISEMENT
1
2Illumina Clinical Services Laboratory – Illumina, Inc.
5200 Illumina Way
San Diego, CA 92122, USA
Phone: 858.736.8080
Fax : 858.736.8600
TEST REQUISITION AND PATIENT INFORMATION
For Individual Genome Sequencing
1. Requested Test
Please select most appropriate indication (Please see for test definitions)
Individual Genome Sequencing
FT-800-1001
$ 9,500
Tumor/Normal Sequencing
FT-800-1002
$10,000
†
Rapid TAT Individual Genome Sequencing
FT-800-1011
$11,900
†
Rapid TAT Tumor/Normal Sequencing
FT-800-1012
$13,000
Reporting Options:
Wellness Screen Interpretation
Technical Data Only
For certain serious medical situations, Illumina sponsors a subsidy program. Please contact us for additional information.
†
A limited number of Rapid Turnaround Time (TAT) samples can be accepted.
Contact the Illumina Clinical Services Laboratory at 858.736.8080 prior to sample submission for approval.
2. Physician and Institution Information
Authorized Physician [Print Name]
NPI#
Institution Name and Mailing Address
Telephone Number
Fax Number
Email
Genetic Counselor
Authorized Physician Signature (Required)
Date (MM/DD/YYYY)
3. Patient Information
*First Name
Middle Initial
Last Name
Sex
African American
Caucasian
Native American
Date of Birth (MM/DD/YYYY)
Ashkenazi Jewish
Hispanic
Other:
Male
Female
Asian/Pacific Islander
Middle Eastern
*Subject Identifiers may be used for IRB-approved study samples
IRB Institution
IRB Protocol Number
4. Clinical Information (Required for Diagnostic Evaluation)
Pertinent Clinical Information (Diagnosis, Symptoms, Family History)
ICD-9 Code(s)
Genes/Regions of Interest
5. Sample Information
Date Sample Obtained (MM/DD/YYYY)
Time
Sample Type (Check all that apply)
Blood in Collection Tube Cancer Sample?
Yes
No
DNA (Extracted)
Cancer Sample?
Yes
No
Tissue Source _________________
Test Requisition and Patient Information v20120918
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical