Please fill in all of the fields below including the submitting provider's name, patient's name, clinical indication for testing, and requested gene list.
A unique gene or panel ID code will be generated upon submission. When using our standard paper Single Gene and Panel Testing Requisition Form, please include this code in the GENE OR CUSTOM PANEL ID box to ensure timely processing.
Enter or copy/paste all requested gene symbols for your custom panel below. Individual gene symbols should be separated by a comma, single space, or one gene symbol per line. Only HUGO Gene Nomenclature Committee (HGNC) approved gene symbols will be accepted.
NOTE: This submission tool does not guarantee complete coverage of the genes. You can verify specific gene coverage by clicking the View Gene Coverage link below after entering your gene symbols.