Propose a Test  

All medical doctors (MDs) can propose genetic tests to be supported by the Foundation.
To do so they must submit the standardised request below to the Foundation that will ask the national representatives whether such proposal is acceptable.
If so the national representative will submit the proposal to the executive committee of the Foundation who will make a final decision based upon the financial possibilities of the Foundation.

 
Family Name:
First Name:
E-mail:
 
Street + Nr:
Postal Code:
City:
Country:
 
Date of Birth:
Gender:
Ethnic Origin:
Insurance Covering Test?: no:
Annual Net Income (in Euro):
 
Disease:
Who is affected?:
Requested Test (with OMIM number if possible):
   
Motivation:
 
Name National Representative:
 
 
 
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