---
title: Simsen Personal — Requisition Form
---

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)

# Simsen Personal

Requisition form

 Please send completed form in the sample kit box.  
**(\*)** denotes required fields. Failure to complete will result in testing delays.  
 Kindly send any inquiries to: [support@simsendiagnostics.com](mailto:support@simsendiagnostics.com)

Place Collection Kit ID Sticker here, please.

1

Patient information

Ordering Clinic / Lab / Organisation \*

Patient ID (pseudonymised) \*

Cancer type \*

Stage \*

I II III IV

Tumour content (%)

 ! Patient IDs must match between the tissue sample and matching blood / plasma samples.

2

Test selection \*

### Simsen® Personal — Initial test

Initial test Establishes the tumour profile and sets up the patient.

#### How is the tumour profile being established?

We sequence the tumour — **FFPE** sample We sequence the tumour — **Fresh Frozen** sample We sequence the tumour — **Extracted DNA** We use **existing sequencing data** you send us

#### Which data will you send? (Select all that apply)

 Tumour sequencing raw data  Normal blood raw data  Tumour profile / Variant Call File (VCF)

#### Pre-defined actionable mutations (optional)

Add pre-defined actionable mutations to the patient's panel — select gene(s) below, up to 16 assays in total (one assay may cover several variants)

#### Select gene(s)

0 of 16 assays selected

All assays of a selected gene are ticked by default — untick any you do not want.

#### Other variant not listed (optional)

Each entry counts as one assay. Simsen will confirm assay availability before processing.

\+ Add another variant

#### Plasma at baseline (optional)

Include a plasma sample now, to start ctDNA monitoring at baseline

### Simsen® Personal — Follow-up

ctDNA follow-up analysis Plasma sample for ongoing ctDNA monitoring. For patients whose tumour profile is already set up.

PRIORITY turnaround time — unless checked, STANDARD turnaround times will apply

3

Sample requirements

| Sample type | Required for this order | Date of collection |
| --- | --- | --- |
| Tumour tissue | — |  |
| EDTA (whole blood) — matched normal | — |  |
| 2× Streck (plasma) | — |  |
| Sequencing data transfer | ✓ | *N/A — provided digitally* |

Select a test above to see which samples are required.

 When you have completed the form, click **Generate PDF**. Print one copy to include with the shipment, and email the PDF to [orders@simsendiagnostics.com](mailto:orders@simsendiagnostics.com).

Reset

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##### SHIPPING ADDRESS

 Simsen Diagnostics AB  
 Pepparedsleden 3  
 431 83 Mölndal, Sweden

##### SUPPORT

[support@simsendiagnostics.com](mailto:support@simsendiagnostics.com)  
 +46 760 22 49 96

##### ORDERS

[orders@simsendiagnostics.com](mailto:orders@simsendiagnostics.com)