Application form

NIFGO - Nederlands Instituut voor Farmaco Genetisch Onderzoek

APPLICATION

Details of applicant:

Name *
Initials *
Adress *
Email *
Gender *
Ethnicity *

Name doctor *
Adress *
Email *

Give the names of the drugs to be tested on:
1.
2.
3.

The price for a pharmacogenetic test is £ 150 for one drug; for two drugs £ 280 and for three drugs £ 410

Pharmacogenetic diagnostics
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 info@diph.co.uk.

 

Leave a Reply

Your email address will not be published. Required fields are marked *

https://www.nifgo.nl/