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