Details of applicant:
Name doctor *
Give the names of the drugs to be tested on:
The price for a pharmacogenetic test is £ 150 for one drug; for two drugs £ 280 and for three drugs £ 410
YES/NO I give permission to NIFGO to send the results of the test also to my doctor so he can discuss the results with me. I am familiar with the fact that NIFGO strongly recommends discussing the results with my doctor.
YES/NO I give NIFGO and with NIFGO collaborating laboratories permission to use the outcome of the test and its DNA material anonymously for scientific purposes.
Mail this form to email@example.com.