external referral to hpv test
Transkrypt
external referral to hpv test
Center for Medical Genetics GENESIS ul. Grudzieniec 4, 60-601 Poznań tel. +4861 848 40 38, fax +4861 851 66 46 www.genesis.pl EXTERNAL REFERRAL TO HPV TEST Information on the referring institution Select a test(s): HPV-HR screening PLN 189.00 Name, address (stamp): HPV 16/18 PLN 115.00 HPV 6/11 PLN 115.00 Patient's data Patient's name and first name (in block letters) : ............................................................................................................................... ............................................................................................................................... Birth date:............................... HPV 16/18 i 6/11 PLN 185.00 HPV test with genotyping of 19 types of high risk: 16,18,26,31,33,35,39,45,51,52,53,56,58,59,66,68,69,73,82 and 6 and 11 – PLN 195.00 HPV test with genotyping of 37 types (of high and low risk): 16, 18, 26,31,33,35,39,45,51,52,53,56,58,59,66,68,69,73,82,6,11,40, 42, 43,44,54,61,62,67,70,71,72,74,81,83,84,91, – PLN 295.00 other test……………………………………………………………………………………………………. Address for delivery of the test result: ............................................................................................................................... ............................................................................................................................. Previous tests, the last results of a cytological and histopathological examination……………………………………………………………………………………………………….………………… ……………………….. Information on biological material Contact phone number:............................................................................................... Type of biological material: ........................................................... Isolated DNA Signature and stamp of the physician referring the patient to the test. Swab of............................. Other .......................... To be filled in by the laboratory: Data pobrania próbki od pacjenta: ............... /............. / .........................r. Date of receiving the material: ............/.............../...................... Person receiving the material/isolating DNA: …........................................................ Dotychczas wykonywane badania, wskazania........................................................... Numer próbki / DNA: Numer wyniku: Account number for bank transfer payment: 75 2490 0005 0000 4600 6544 0417 at ALIOR BANK SWIFT code: ALBPPLPW Individual patients are asked to make payment before the test. ……………………………………….. Date ……………………………………….. Customer signature Detailed information is available at www.genesis.pl Genesis Polska sp. z o.o. / ul. Za Cytadelą 19 / 60-659 Poznań/ tel. +4861 848 40 38 / fax +4861 851 66 46 NIP 778 13 56 527 / REGON 631002980 / Sąd Rejonowy Poznań – Nowe Miasto I Wilda w Poznaniu, VIII Wydział Gospodarczy Krajowego Rejestru Sądowego KRS nr 0000169935 / Share capital 50 000 zł./wyd.2/28.05.2012