Your request

Request Form

Complete the steps below to submit your test request. Our clinical team will review and follow up within one working day.

Pathway

Patient

Clinician

Funding

Sample

Review

Patient details

Tell us about the patient being referred for testing.

Patient full name *

Date of birth *

Sex

NHS number (optional)

Email address *

Phone number *

Patient address

Clinical notes / reason for testing

Family history of cancer

Family history helps clinicians assess hereditary risk and determine the most appropriate panel. Include any known cancer diagnoses in close relatives.

Does the patient have a family history of cancer? *

Yes No Unknown

Relative 1

Relationship to patient

Cancer type

Age at diagnosis (approx.)

Alive / deceased

Additional family history notes (optional)

Clinician & referral details

Provide details of the referring or treating clinician so we can coordinate results and follow-up.

Referring clinician

Clinician name *

GMC / registration number

Clinician email

Clinician phone

Hospital / institution *

Department / specialty

Referral context

Referral notes (optional)

Funding & payment

Tell us how this testing will be funded so we can process your request appropriately.

Funding route *

NHS funded Testing funded through the National Health Service Private insurance Testing funded by a health insurance provider Self-pay Patient paying directly for testing Research / clinical trial Testing funded through a research study or trial

NHS funding details

NHS Trust *

PO number (if known)

Cost centre or budget code (optional)

Insurance details

Insurance provider *

Policy number *

Insurance provider name

Pre-authorisation reference (if available)

Membership / certificate number

Self-pay information

Pricing information

Our team will provide a detailed cost breakdown and payment options after reviewing your request. No payment is taken at this stage.

I understand that pricing will be confirmed before any testing begins

Research / trial details

Study / trial name

IRAS / ethics reference

Principal investigator

Sample & consent

Confirm sample details for each test, then provide the necessary consents.

Consent

Patient consent is required

The patient (or their legal representative) must provide informed consent before testing can begin.

The patient has provided informed consent for the requested testing * The patient consents to their data being processed in accordance with our privacy policy * The patient consents to anonymised data being used for research purposes (optional)

Supporting documents (optional)

Upload any relevant documents such as referral letters, previous test results, or clinical notes.

Drop files here or

PDF, DOC, JPG, PNG — max 10 MB per file

Review & submit

Review your request below. Click any section to go back and make changes.

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