ASPER ENDOCRINOLOGY SAMPLE SUBMISSION FORM

ORDERING PERSON AND REPORTING INFORMATION / ADDITIONAL REPORTING INFORMATION
(if applicable)
Name
(first name,
last name)
Institution
Address
E-mail
Phone
Results delivery / by e-mail by regular mail
Sample receipt confirmation / Person
E-mail
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
E-mail
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
Fetal sample (for prenatal testing) / Maternal sample (for prenatal testing)
Date of collection
Type / DNA from CVS DNA from
amniocentesis / DNA whole blood in EDTA
Method and/or kit of DNA extraction
PATIENT INFORMATION
Name
Date of birth
Sex
Ethnic origin
Clinical diagnosis

TESTS REQUIRED

Androgen Insensitivity Syndrome / Sequencing of AR gene
Single mutation
Del/dup analysis of AR gene
Combined Pituitary Hormone Deficiency / NGS panel of genes
Single mutation
Del/dup analysis of GH1, GHRHR, HESX1, LHX3, LHX4, POU1F1, PROP1 genes
Familial Hypocalciuric Hypercalcemia / Sequencing of CASR gene
Single mutation
Del/dup analysis of CASR gene
Hypothyroidism and Thyroid Hormone Resistance / NGS panel of genes
Single mutation
Del/dup analysis of GNAS gene
Maturity Onset Diabetes of the Young (MODY) / NGS panel of genes
Single mutation /
Del/dup analysis of CEL, GCK, HNF1A, HNF4A, HNF1B, INS, KLF11, NEUROD1, PAX4, PDX1 genes
Thyroid Dyshormonogenesis / NGS panel of genes /
Single mutation /
Del/dup analysis of FOXE1, NKX2-1, PAX8, TPO, TSHR genes

Service includes

DNA extraction

Genotyping

Confirmation of disease associated variants by Sanger sequencing

Interpretation

The results report by registered mail

Targeted mutation analyses results 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 diagnosis carrier testing

Age at the onset of symptoms…………......

Diabetes mellitus

Hypoparathyroidism

Hyperparathyroidism

Hypothyroidism

Hyperthyroidism

Growth retardation

Infertility

Genitourinary findings…………………………………………………………………………………………………………….

Immunological findings…………………………………………………………………………………………………………...

Other findings………………………………………………………………………………………………………......

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 • • www.asperbio.com