Get Perkinelmer Genetics Clinical Genomics Requisition Form

Completing the PerkinElmer Genetics Clinical Genomics Requisition Form online is a straightforward process that requires attention to detail for accurate gene testing. This guide provides comprehensive instructions to help you fill out each section effectively.

Follow the steps to complete the requisition form accurately.

1. Press the ‘Get Form’ button to access the requisition form online.
2. Fill out the patient information section. Provide the patient's first and last name, date of birth in MM/DD/YYYY format, and contact details including street address, city, state, zip code, and preferred phone number.
3. In the patient sample information section, select the sample type by ticking the appropriate box: Saliva Swab, Whole Blood, Dried Blood Spots, or Other. Note the collection date and age of manifestation, and include relevant ICD10 codes.
4. Fill out the test menu section by selecting the biological sex of the patient and any applicable gender identity. Indicate the type of genomic test desired (Exome or Genome) and if additional optional testing enhancements are required.
5. Complete the familial information section only if a TRIO test is ordered. Include necessary details for the biological mother, biological father, and any additional family members, including their names, dates of birth, and if they are symptomatic.
6. Provide information regarding the healthcare provider who will be ordering the test. Include their name, contact details, and institution information.
7. Fill out the billing information section to specify whether the payment is from an institution or self-pay. Provide all necessary billing details as required.
8. Fill out the phenotype/patient history section by checking applicable conditions. Attach any required detailed medical records or clinical summaries.
9. Review all completed fields for accuracy before submitting the form. You can save changes, download, print, or share the form as needed.

Complete your requisition forms online today for efficient processing.