Partner's / Distributor's information:
Company Name
Full Name
E-mail (CC address of order form)
Consultant name (optional)
Consultant E-mail (optional)
Patient information:
DNA kit barcode number
E-mail
First name
Family name
Ancestry EuropeanEast-AsianSouth-AsianAfricanMixed
National identification number
Phone
Comment (optional)
DNA kit shipping information (optional):
Address
City
Postal Code
Country
Select tests:
AnteCancerW (A set of genetic risk tests for women)AnteCancerM (A set of genetic risk tests for men)AnteBC (polygenic risk score test of breast cancer)AntePC (polygenic risk score test of prostate cancer)AnteCRC (polygenic risk score test of colorectal cancer)AnteMEL (polygenic risk score test of melanoma)
Consent:
By ordering this service I confirm that the patient has been made aware of data processing under the provisions of Antegenes terms of use and privacy conditions.
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