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
Do you need to send a kit to the patient’s home?
Kit Type (select all that apply)
Patient Contact Information
Shipping Information
Special Instructions