aHUS Genetic Testing Sponsorship Enrollment

HomeaHUS Genetic Testing Sponsorship Enrollment

The Alexion Sponsored Testing (pilot) Program for prognostic aHUS genetic testing has concluded.

We are pleased to report that all samples submitted through the program were resulted within 1 week of specimen receipt AND surveyed clinical sites reported a “10 out of 10” for program satisfaction.

We would be happy to service your genetic testing needs through other channels, including other sponsored testing programs, (just call 1-800-566-3462 or email: info@machaondiagnostics.com).

Intake

Who is completing this form? (Samples submitted by patients completing this form will not be processed.)*

Is this patient currently an inpatient?*

Hospital lab phone

Patient

First Name*

Last Name*

Middle Initial

Date of Birth*

Gender at Birth*

Ethnicity

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Phone*

Email*

Physician

First Name*

Last Name*

Middle Initial

NPI#

Type*

Hospital Association

Clinical Setting*

City*

State*

Zip Code*

Phone*

Fax

Other

What is the ICD-10 code associated with this patient?*

Has TTP been ruled out by testing an ADAMTS13 activity?*

ADAMTS13 Activity*

Has the patient been tested for aHUS genetics previously?*

Has the patient received a bone marrow transplant?*

Does the ordering physician acknowledge that some de-identified patient and de-identified physician information will be shared with the program sponsor?*

Does the ordering physician agree to be surveyed on their use of the program?*

What is the ordering physician's preferred method of receiving the results?*

How did you hear about this program?*

Do you commit not to bill third parties for this testing?*

Quality Assurance: Can Machaon check in with you after you receive the result to ensure everything went smoothly?*

Would you like to be contacted to schedule a clinical consultation as part of this patient enrollment?*

Is the ordering physician's primary practice in one of these states?*

When do you typically assess your aHUS patient’s long-term prognosis?*

If you are not using genetic testing or using it in less than 50% of aHUS cases, why have you not used it more?*

Are you typically using genetic consultation services provided by the laboratory when requesting genetic testing, either before or after the test?*

By submitting this form, you consent to sharing some data with Machaon Diagnostics and Alexion Pharmaceuticals.