Genetic test requisition
Order form for PANEL Tribro, WES Tribro, WGS Tribro, RNASEQ Tribro and related analyses.
1. Patient
Patient ID
Name
Date of birth
Biological sex
Family ID
Ancestry (optional)
2. Requesting clinician
Name
Institution
Email
Phone
3. Test requested
☐ Gene panel — code TBO-GP-____ ☐ Whole-exome sequencing ☐ Whole-genome sequencing ☐ RNA sequencing
☐ Mitochondrial genome ☐ CNV analysis ☐ Structural variants ☐ Repeat expansion ☐ Methylation profiling
Design: ☐ Singleton ☐ Duo ☐ Trio ☐ Other: ________ Priority: ☐ Routine ☐ Urgent (reason: ____________)
Secondary findings: ☐ Report ☐ Do not report (must match the signed consent)
4. Clinical information
Indication and clinical question
| HPO ID | Phenotype term | Present / excluded | Age of onset |
|---|---|---|---|
| HP: | |||
| HP: | |||
| HP: | |||
| HP: | |||
| HP: | |||
| HP: | |||
| HP: | |||
| HP: |
Relevant family history; consanguinity
Previous genetic tests and results
5. Sample
Sample type (blood EDTA / DNA / saliva / tissue / RNA)
Collection date and time
Sample ID / barcode
Collected by
| Family member sample | Relationship | Affected? | Sample ID |
|---|---|---|---|
6. Declaration
I confirm that informed consent has been obtained and that the clinical information given is accurate.
Clinician signature
Date
© Tribro-Omics · Genetic test requisition · Version 1.0 · 11 November 2026