TEST REQUISITION FORM
Each sample must be accompanied by this completed requisition.
*
Fields are mandatory
1: Test Details
Test Name*
Sample type* (Kits used for DNA Extraction)
Initial DNA concentration* (using Qubit IX ds DNA BR ASSAy kit)
DNA Integrity* (Tapestation HS D1000)
2: Patient Details
Patient Name*
D.O.B
Age
Gender*
select
Male
Female
Address
Phone
E-mail I.D
3: Lab Details (Department)
Date of sample collection*
Clinical notes/diagnosis
Technical officer name
Student name
Project name
Purpose of study
Disease affection status
Yes
No
Parental consanguinity present
Yes
No
Age of manefestation
Affected Sibllings
Yes
No
Details
Pedigree / Family History
Depatment Name*
Select
Clinical & Experimental Immunology
Cytogenetics
Haematogenetics
Haemostasis and Thrombosis
Pediatric Immunology & Leukocyte Biology
Transfusion Medicine
Transfusion Transmitted Diseases
Date*
Place
Submit