PerkinElmer Genomics

Order Submission and Kit Request for Patient Form

This form should be used to submit test orders to PerkinElmer Genomics. Health care providers can also request that a kit be sent directly to the patient’s home for sample collection, if needed.

Test Requisition Submission

Please upload your fully completed and signed test requisition here. You may also include informed consents and applicable clinical notes with the requisition.

If you still need to complete a test requisition form for submission, they can be found here.

Drop PDF documents here

Physician Contact Information

Full Name *

Phone *

Email Address *

Confirm Email Address *

Institution *

Do you need to send a kit to the patient’s home?

Yes No

Special Instructions