A / DIAGNOSTICS · INTAKE

Sample Submission

Submit a diagnostic sample to Gene Negar Ayandegan. Please complete every required field; our intake team will verify the request and contact the referring physician or laboratory if any clarification is needed.

Go to Laboratory Portal →Already have an account? Track and manage submissions in the secure portal.

This intake form is for pre-registration. Final acceptance of the sample depends on physical inspection at the laboratory and signed informed consent.

1. Requester information

Requester type *Organization / center name Contact person *Email *Phone *City

2. Patient information

Patient first name *Patient last name *National ID / MRN Sex *Date of birth Ethnicity / origin Parental consanguinity

YesNoUnknown

3. Sample information

Sample type *Collection date Container / tube ID Volume / quantity Shipping method Shipment tracking code Storage & transport notes

4. Test selection

Requested test *Preferred method Priority *

5. Clinical information

Clinical indication *Family history Previous tests / results Referring physician

6. Consent & confirmation

I confirm that the patient (or legal guardian) has provided informed consent for genetic testing. *I authorize Gene Negar Ayandegan to process the sample and personal data for diagnostic purposes only. *Optional: I authorize anonymized use of residual sample and data for internal research and quality improvement.

* Required