1. No category

Requisition - Molecular diagnostics
Rikke Møller/ Ditte Kjelgaard
Laboratoriet
Kolonivej 11
4293 Dianalund
Denmark
Patient:
Referring physician:
Name:
Name:
Hospital:
Date of birth:
Phone number:
Seizure onset:
E-mail:
Indication / Diagnosis :
Genetic analysis:
◯
Childhood Epilepsy Panel (incl. encephalopathy)
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Progressive Myoclonic Epilepsy Panel
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Brain Malformation Panel
Type of biological material:
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EDTA- stabilized blood (min. 5 ml.)
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DNA (min. 2 g)
Consent:
Payment:
Date:
◯
IBAN-number: DK 453 000 000 6406319
Referring physician:
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SWIFT: DABADKKK
◯
The Letter of Guarantee
Ditte Kjelgaard Genetic assistant [email protected] +45 6120 1751
Version 1.1, 04-05-15, dbk