


REGISTRATION FORM

Main Details

Contact Details

Important: Please provide a minimum of 2 names to whom all samples and correspondence should addressed

UK Participants: To avoid delays in processing your re-registration, please ensure an invoice contact is entered on the 'Contact Details' tab above

For security reasons, changes to the default contact details cannot be made online. Please contact UKNEQAS LI Staff with any changes.

Default Contact

Trial Contact

Title:

Forename(s):

Surname:

Email:

Tel No:

Fax No:

Department:

Hospital:

Street:

District:

Town/City:

Postcode:

Country:

Notify contact of genetic trial and report issues:

Currency:

Courier Services Required:

You will be contacted about the costs of this service.

Order Number:

V.A.T.A Number:

Would European Participants please note that all prices are EX-VAT, but without the provision of a VATA Number for your site
we will be legally obliged to charge VAT at UK rates (currently 20% but this may be subject to change without notification). Do Not enter country prefix as part of your VAT Number, this will be added automatically.

We would like to join the following programmes. Please tick as appropriate

Programme

Price

Leukaemia Diagnostic Interpretation (Parts 1 & 2)

�530

Leukaemia Diagnostic Interpretation (Part 2 Institute)

�209

Leukaemia Diagnostic Interpretation (Part 2 Individual)

�0

Immune Monitoring

�520

CD34 Stem Cell

�520

Low Level Leucocytes

�1244

Options:	Flow Cytometry	Nageotte

Machine 1 Name
Flow Cytometer

Machine 2 Name
Flow Cytometer

Minimal Residual Disease - ALL

�360

JAK2 p.Val617Phe (V617F) Mutation Status

�244

BCR-ABL1 Quantification

�244

Chimerism

�320

IgH/TCR Clonality

�244

FLT3 Mutation Status

�244

NPM1 Mutation Status

�244

BCR-ABL Kinase Domain Mutations (not accredited)

�242

BRAF p.Val600Glu (V600E) Mutation Status for Hairy Cell Leukaemia

�244

KIT p.Asp816Val (D816V) Mutation Status for Mast Cell Disease

�244

Pilot Paediatric Acute Leukaemia Translocations (not accredited)

�242

Pilot Minor BCR-ABL1 Quantitation (not accredited)

�202

Immune Monitoring Alt.Technology (not accredited)

�520

Minimal Residual Disease - BCLL (not accredited)

�266

Haematological Malignancy Bone Marrow Aspirate Assessment Pre-Pilot

�0

Minimal Residual Disease - AML (not accredited)

�266

BCR-ABL1 and AML Translocations

�244

Paroxysmal Nocturnal Haemoglobinuria (April 2016+)

�397

Pilot Acute Myeloid Leukaemia Gene Panels (Not Accredited)

�51

Please tick to confirm that you agree to participate in the above programmes as selected and will abide by the conditions of participation for
UK laboratories. These are available here

Please tick to confirm that you agree to participate in the above programmes as selected and will abide by the conditions of participation for
Non-UK laboratories. These are available here

Title:		Department:
Forename(s):		Hospital:
Surname:		Street:
Email:		District:
Tel No:		Town/City:
Fax No:		Postcode:
		Country:
	Notify contact of genetic trial and report issues:

Title:		Department:
Forename(s):		Hospital:
Surname:		Street:
Email:		District:
Tel No:		Town/City:
Fax No:		Postcode:
		Country:
	Notify contact of genetic trial and report issues:

Title:		Department:
Forename(s):		Hospital:
Surname:		Street:
Email:		District:
Tel No:		Town/City:
Fax No:		Postcode:
		Country:
	Notify contact of genetic trial and report issues:

Title:		Department:
Forename(s):		Hospital:
Surname:		Street:
Email:		District:
Tel No:		Town/City:
Fax No:		Postcode:
		Country:
	Notify contact of genetic trial and report issues:

Title:		Department:
Forename(s):		Hospital:
Surname:		Street:
Email:		District:
Tel No:		Town/City:
Fax No:		Postcode:
		Country:
	Notify contact of genetic trial and report issues:

Title:		Department:
Forename(s):		Hospital:
Surname:		Street:
Email:		District:
Tel No:		Town/City:
Fax No:		Postcode:
		Country:
	Notify contact of genetic trial and report issues:

Contact Type