Request
A Quote
All information provided in this form
is confidential.

Please fill out the entire form and click the "Submit" button at the bottom
of this page.

A Gentris representative will contact you after your on-line inquiry is received.

If you have any questions, please call Gentris at 919-465-0100
  Gentris Corporation Toxicogenomics Request Form
 
  * Required fields
   
  Your Company Name
  *
   
  Study Contact Information
Name *
Address *
Phone *
E-mail *
   
  How Did You Hear About Gentris?
 
   
  Protocol/Study Number
  *
   
  Protocol/Study Title
 
   
  Duration of Study
Start (mm-dd-yyyy format)
End (mm-dd-yyyy format)
   
 
Types of Services Requested
   
  Nucleic Acid Extraction
   
  DNA Extraction From    
       
  Species    
     
       
    Number of Samples  
  Whole Blood  
  FFPE Tissue  
  Tail Snips  
  Cell Lines  
  Buffy Coats  
  Tissue - Fresh  
  Tissue - Frozen  
       
  RNA Extraction From Number of Samples  
  Whole Blood  
  FFPE Tissue  
  Tail Snips  
  Cell Lines  
  Buffy Coats  
  Tissue - Fresh  
  Tissue - Frozen  
       
   
  Genotyping
   
  Species Number of Samples  
   
       
  List genes to be tested Alleles / Mutations (if known)
   
   
   
       
  qRT-PCR
   
  Gene Expression
   
  Species Number of Samples  
   
   
  List genes to be tested Alleles / Mutations (if known)
   
   
       
  Microarray Testing
       
  DNA Array    
 

Number of Samples

 Species
 
    Chips  
   
  RNA Microarray
 

Number of Samples

 Species
 
    Chips  
   
 
  Sample Banking
   
  DNA
  RNA
  PLASMA
  Serum
  Tissue
   
  Please list any others
 
   
  Duration (years)
 
   
   
  Sample Submission Form (SSFs) and Lab (for Human) Manual

(To Maintain Chain-Of-Custody)
Yes No
   
  Return Shipping Kits

(Includes gel pack, all necessary packaging materials, IATA labels, preprinted FedEx return air waybill, Shipment Notification Form, FedEx Clinical Pack)
Yes No
   
  Collection Supplies
  (i.e. blood collection tubes and/or tissue collection supplies) required-type
  6 mL EDTA tubes
  10 mL EDTA tubes
  2 mL Cryovial
  PAXgene DNA tubes
  PAXgene RNA tubes
   
  Please list any others
   
  If Kits Are Required
  Dry Ice Shipping Kit Number of Kits Needed
  Gel Pack Shipping Kit Number of Kits Needed
       
    Number of Domestic Sites
    Number of International Sites
   
  Miscellaneous Comments (please provide any additional information)
 
 
 
 
 
 
 
 
   
 
   
Gentris Corporation - 133 Southcenter Court Suite 400 - Morrisville, North Carolina 27560 - 919-465-0100 - PGx@gentris.com