MPRS Service Request Form

General Instructions:

  1. Fill out the form below. Samples need to be labeled with unique identifiers.
  2. If paying with a VCU account, create a PO in eVA.  Our Tax ID # is 54-1581185 and our V # is V00220314.
  3. Bring form, with approved PO #, and Excel file containing the list of specimen unique identifier(s)  and specimens to Molecular Diagnostics Laboratory. Please contact the lab prior to bringing the samples to ensure that someone is available to receive the samples. The laboratory location is listed below:

    Molecular Diagnostics Laboratory
    Clinical Support Center Building 
    (Between D Deck and North Hospital)
    2nd Floor Room 247
    Richmond VA 23298-0248
    Phone: 804-828-9564
    Fax: 804-827-4738
    For all questions regarding PO creation please contact Pathology Finance at 804-827-8367

Services Offered:

  • Tier 1: Ion AmpliSeq™ Cancer Hotspot Panel v2 (50-gene Cancer Panel) VCF file
  • Tier 2:  Ion AmpliSeq™ Cancer Hotspot Panel v2 (50-gene Cancer Panel) VCF file + Annotations
  • Tier 3:  Ion AmpliSeq™ Cancer Hotspot Panel v2 (50-gene Cancer Panel) VCF file + Annotations + Clinical Interpretation

 

Request Form:
(All fields are required)





 

Please list the Sample Unique Identifiers as labeled on the tube:

Please note: at least 1 Sample Unique Identifier, Tier & Description needs to be filled in.



Sample 1

Sample 2

Sample 3

Sample 4

Sample 5