Liquid Biopsy NGS Service Request Form

1. Customer Information

Provide the primary contact responsible for the request.

Organization

Department

Contact name

Email

Telephone

Customer or account number

Billing address

Purchase order number

Quote number

2. Project and Requested Services

Select all services that apply. No option is selected by default.

Requested liquid biopsy services

Project title

Study, protocol, or project ID

Reference genome

Expected number of samples

Project objective

Sequencing Design

Panel type

Panel name or application

Requested sequencing depth

UMI / molecular barcode preference

Requested variant allele fraction threshold

Target nucleic acid input

Genes, hotspots, regions, or supplied design

Requested Analysis

Analysis types

Matched reference material

Longitudinal samples

3. Deliverables and Data Analysis

Select all requested outputs. Final scope and reporting format are confirmed during review.

Preferred pipeline or software

Additional file formats

Filtering, annotation, comparison, or reporting requirements

4. Sample Information

Add one record for each submitted sample. Use coded identifiers only.

5. Shipping and Data Delivery

Planned shipment date

Carrier

Tracking number

Shipping condition

Requested turnaround

Preferred data delivery

Shipping, handling, or data-transfer notes

6. Customer Authorization

The submitting customer must review and accept the statements below.

I certify that the information is accurate and the submitted materials are authorized for the requested research service.I certify that the submission contains no direct patient identifiers or protected health information.I have disclosed all known biological hazards, infectious agents, and special handling requirements.

Authorized name

Title

Date

Electronic signature

7. Laboratory Use Only

Accession or project number

Date received

Received by

Condition on receipt

Sample acceptance

Technical review

Laboratory notes

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Liquid Biopsy NGS Service Request

Liquid Biopsy Project Request Form