Patient Sample Application Form

Personal Genetic Color Profile Determination – Skin Sample Collection and Registration Form

Patient Information

Full Name

Date of Birth

ID Number / Passport Number

Contact (Phone / Email)

Application Date

Doctor Information

Full Name

Specialty

Affiliated Institution

Signature / Stamp

Sample Collection Information

Collection Method

Swab Method from Skin Surface (Dermaroller / Micro-needle device) Stratum Corneum Adhesive Tape Method (Tape-Strip)

Sample Collection Area

Forehead Cheek Arm Other

Collection Date

Collection Time

Sample Code Alias

Sample Shipment

Shipment Date

Sender

Courier / Delivery Company Information

Tracking Number

As the undersigned, I consent to the use of my skin sample for genetic (DNA/RNA) analysis, the sharing of analysis results only with my authorized doctor, and the extraction of my genetic color profile within the scope of Genoscope.

I have read and accept the KVKK Clarification Text.

Full Name

Date

Note: The sample must be stored under sterile conditions at the appropriate temperature and delivered to the Genoscope Analysis Center within eight hours at the latest. Delayed shipments will be subject to quality control.