Targeted Gene Panel Sequencing Order Sheet
Ordering Physician
Department / Institution
Contact Information
Patient Name
Date of Birth
Patient ID
Gender
Sample Type
Sample ID
Date Collected
Diagnosis
Requested Gene Panel
Additional Genes to Include
Clinical Indication / Reason for Testing
Family History
Requested Analyses
Turnaround Time Requested
Gene
Transcript / Reference
Reason / Notes
Additional Comments
Physician Signature
Date