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Referral Form

For Genetic Testing E.420-23A

Patient Information

Sex

Detailed Clinical History

Is the patient affected?
Is there a sibling who is similarly affected?
Is there consanguinity between the parents?

Relatives Being Tested

Test Details

Sample type

Requested Test

Requested Test

Additional Tests

Additional Tests

Referrals & Treatment Information

Has the patient undergone a transfusion?
NOTE: At least 2 weeks are required from the last transfusion before the patient can undergo the genetic test.
Has the patient undergone an allogeneic bone marrow transplant?
The sample was collected:
NOTE: Buccal swabs are recommended for patients who have undergone an allogeneic bone marrow transplant.

Referring Physician Details

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