Decode Duchenne: Online Application Form

 

This form is intended for use by healthcare providers. If you are a patient or a family member and would like to request testing, please contact us.

PLEASE NOTE: This application is ONLY for female carrier testing. An application is no longer required for diagnostic testing. Go directly to the PerkinElmer website to order diagnostic testing.

 

PARTICIPANT(PATIENT) INFORMATION

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(Maximum response 255 chars, approx. 5 rows of text)

 

PROVIDER INFORMATION

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Would you like specimen shipping kits sent to your office? (PerkinElmer lab kit(s) will be shipped to address above.) If yes, please provide the following information:

   


   


 

Saliva kits can be shipped directly to a patient's home, but the ordering provider must request the kit directly on the PerkinElmer website and must first upload the completed TRF. Directions will be sent via email with the TRF.

   


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Please confirm that this participant:

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Question - Required - I attest that my patient:

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Question - Required - I attest that my patient:

 

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Question - Not Required - If no, how did you hear about the program?

 

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De-identified data from the Decode Duchenne program may be shared with industry sponsors, including Sarepta and PTC Therapeutics. This de-identified data may be used for diagnostic and therapeutic disease research, such as understanding the incidence of certain dystrophin gene mutations, evaluating and improving the diagnosis of Duchenne/Becker, and developing novel mutation-specific therapeutic strategies.

   Please leave this field empty