Please fill out the relevant boxes and then click on the Send button


ORDER FORM

Sample kits and information are supplied free of charge. You will be invoiced for
Amnio-PCR after we recieve your sample.

   
Do you wish to order : .
Patient Details:
Patient Name : .
Patient Address : .
Patient Telephone : .
Patient Email : .

Appointment Details:
The results from your Amnio-PCR will be sent to your consultant directly
Consultant's Name : .
Consultant's Address : .
(hospital or clinic) .
Consultant's Telephone : .
Consultant's Fax : .
Date of Amniocentesis : .
Time of Appointment : .
Place of Appointment : .
We can send this kit directly to your consultant if you prefer. many obstetric departments
already hold our sample kits and we will inform you if your consultant already has a supply.
Delivery details of sample kit:
Delivery Address : .
(If different from above) .