ASPER WELLNESS SAMPLE SUBMISSION FORM
ORDERING PERSON AND REPORTING
INFORMATION
ADDITIONAL REPORTING INFORMATION
(if applicable)
Name
(first name,
last name)
Institution
Address
E-mail
Phone
Results delivery
Sample receipt
confirmation
by e-mail
by regular mail
Person
E-mail
BILLING INFORMATION
By submitting DNA samples to Asper Biotech the client agrees that invoices shall be paid within 10 calendar days as of the invoice date and in
case of delay in the payment, the open invoice amounts will accrue interest amounting to 0,1 % per calendar day.
Contact person
Institution
Address
E-mail
Phone
VAT account
number
In EU countries please add paying institution's VAT account number, otherwise 20% of VAT tax will be added to the invoice.
PO number
Invoice delivery
by e-mail
by regular mail
SAMPLE INFORMATION
Type
whole blood in EDTA
DNA
Other......................................
Date of collection
PATIENT INFORMATION (needed for diagnostic package)
Name
Date of birth
Sex
Ethnic origin
Clinical diagnosis
ASPER BIOTECH Ltd • reg Nº 10504931 • Vaksali 17A, 50410 Tartu, Estonia
phone +372 7307 295 • fax +372 7307 298 • info@asperbio.com • www.asperbio.com
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TESTS REQUIRED
Genotyping service
Standard delivery*
Genotyping service
Express delivery**
Diagnostic
package***
Number of samples
Number of samples
Number of samples
Targeted mutation analysis
Age-related Macular
Degeneration
N/A
NGS panel of 21 genes
N/A
N/A
Single mutation
Alzheimer Disease,
Recovery from
Traumatic Brain Injury,
Coronary Heart
Disease
Targeted mutation analysis
N/A
N/A
Celiac Disease
Targeted mutation analysis
N/A
N/A
Lactose Intolerance
Targeted mutation analysis
N/A
N/A
Venous Thrombosis
Targeted mutation analysis
N/A
N/A
* - Genotyping service (standard delivery)
Genotyping
The results report by e-mail
APEX-based test results will be delivered by 3-6 weeks
NGS-based test results will be delivered by 8 weeks
For further information about turnaround times see the detailed description of each test on http://www.asperbio.com/
Genotyping results are for research use only. Genetic counseling is recommended to follow the genetic testing.
** - Genotyping service (express delivery)
Genotyping
The results report by e-mail
The results will be delivered by 7 working days
The express delivery is 45 EUR higher than the standard delivery.
*** - Diagnostic package
DNA extraction
Genotyping
Confirmation of disease associated variants by Sanger sequencing
Interpretation
The results report by registered mail
APEX-based test results will be delivered by 3-6 weeks
NGS-based test results will be delivered by 12 weeks
For diagnostic package please fill in patient’s clinical information at the end of the form.
Supportive services for genotyping
DNA extraction from blood, saliva or formalin-fixed paraffin-embedded tissue (35 €)
Confirmation of the APEX-based analysis findings by Sanger sequencing (29 € per mutation)
Confirmation of the NGS-based analysis findings by Sanger sequencing (29 or 140€ per mutation)
Hard copy of the genotyping results (23 €)
Sample return by courier (95 €)
Shipping address.......................................................................................................................................................................
Sample return by postal parcel (49 €)
Shipping address.......................................................................................................................................................................
ASPER BIOTECH Ltd • reg Nº 10504931 • Vaksali 17A, 50410 Tartu, Estonia
phone +372 7307 295 • fax +372 7307 298 • info@asperbio.com • www.asperbio.com
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SAMPLE INFORMATION FOR GENOTYPING SERVICE
Sample code
(samples should be pre-coded when
sent to Asper Biotech)
DNA concentration
(preferred 100-250 ng/µl)
Comments/Patient’s data
(fill the field if patient’s data is
needed for reporting and invoicing)
COMMENTS
PATIENT’S CLINICAL INFORMATION (needed for diagnostic package)
Reason for referral
confirmation of clinical diagnosis
presymptomatic testing
risk assessment
Age at the onset of symptoms………….............................
anemia
weight loss
muscle atrophy
gastrointestinal findings……………………………………………………………………………………………………….....
.......................................................................................................................................................................................
other findings……………………………………………………………………………………………………….....................
Results of the serological analyses (if applicable):
Anti-tissue transglutaminase antibody IgA (tTG IgA)………………………………………………………...U/ml
Anti-tissue transglutaminase antibody IgG (tTG IgG)………………………………………………………..U/ml
Anti-endomysial antibody IgA (EMA IgA)……………………………………………………………………...U/ml
Deamidated gliadin peptide antibody IgA (DGP IgA)………………………………………………………...U/ml
Deamidated gliadin peptide antibody IgG (DGP IgG)………………………………………………………..U/ml
Venous thrombosis (VT)
idiopathic VT
recurrent VT
life-threatening VT(pulmonary embolus, cerebral vein thrombosis etc)
at an unusual site (cerebral, mesenteric, portal, hepatic)
while on oral contraceptives/ hormone replacement / methotrexate therapy
pregnancy and postpartum period associated VT
recurrent fetal loss ( 2nd and 3rd trimester)
Arterial thrombosis
stroke
myocardial infarction
Previous genetic testing
not done
results:
.....................................................................................................................................................................................
.....................................................................................................................................................................................
ASPER BIOTECH Ltd • reg Nº 10504931 • Vaksali 17A, 50410 Tartu, Estonia
phone +372 7307 295 • fax +372 7307 298 • info@asperbio.com • www.asperbio.com
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Family history
unknown
diagnosis…………………………………………………………………………………………………………......................
specify the relation to the proband………………………………………………………………………………...................
Important: By sending samples and placing an order customer accepts the Terms and Conditions of Asper Biotech
(see website for details).
ASPER BIOTECH Ltd • reg Nº 10504931 • Vaksali 17A, 50410 Tartu, Estonia
phone +372 7307 295 • fax +372 7307 298 • info@asperbio.com • www.asperbio.com
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