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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 carrier or asymptomatic testing. An application is no longer required for diagnostic testing.
Go directly to the Revvity Omics website to order diagnostic testing.
Participant (Patient) Information
Patient Name
*
Date of Birth
*
Sex at Birth
*
– Select –
Female
Male
Indeterminate
Patient Street
*
Patient City
*
Patient State
*
Patient Zip
*
Provider Information
Provider First Name
*
Provider Last Name
*
Clinical Title
*
Institution
*
Street Address
*
City
*
State
*
– Select –
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Ohio
Oklahoma
Oregon
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Texas
Utah
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Country
*
– Select –
Afghanistan
Aland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People’s Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
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New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Norway
Oman
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Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Vietnam
Virgin Islands, British
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Fax Number
*
Phone
*
Email (Note: Paperwork for testing, including requisition and specimen kit ordering instructions, will be sent to this email following approval of application.)
*
Yes, I would like to be added to PPMD's email marketing list.
SPECIMEN COLLECTION KITS
The following types of kits are available from Revvity Omics:
Blood
Dried Blood Spot cards
Saliva
Saliva kits can be shipped directly to a patient's home, but the ordering provider must request the kit directly on the Revvity website, and must first upload the completed requisition. Directions for ordering kits will be sent via secure email or fax with the requisition attached.
Is this patient currently in clinic or coming into clinic today? (If yes, we will send the requisition today, assuming we receive application between 8-5 ET M-F.)
*
– Select –
Yes
No
Please Confirm That This Participant:
I attest that my patient is:
A citizen or resident of the United States or Canada
*
I attest that my patient is....
*
– Select –
An asymptomatic individual of an affected relative with a known causative DMD variant, OR
An asymptomatic individual of an affected relative with NO known causative DMD variant
Since carrier or familial variant testing is being requested, please enter information regarding patient's affected relative including: Name, relationship to patient, date of testing, and DMD variant identified
Have you used Decode Duchenne in the past?
*
– Select –
Yes
No
Others questions or comments:
I attest that I am a healthcare provider (physician/nurse/genetic counselor) directly involved in the evaluation and treatment of this patient. I attest that the information provided on this application is true, accurate and complete to the best of my knowledge and I understand that I am liable for any falsification or omission of information.
*
– Select –
True
False
De-identified data from the Decode Duchenne program may be shared with industry sponsors, including founding sponsor Sarepta Therapeutics and other industry sponsors. This de-identified data may be used for diagnostic and therapeutic disease research, such as understanding the incidence of certain dystrophin gene variants, evaluating and improving the diagnosis of Duchenne/Becker, and developing novel variant-specific therapeutic strategies.
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 carrier or asymptomatic testing. An application is no longer required for diagnostic testing.
Go directly to the Revvity Omics website to order diagnostic testing.
Participant (Patient) Information
Patient Name
Date of Birth
Sex at Birth
Patient Street
Patient City
Patient State
Patient Zip
Provider Information
Provider First Name
Provider Last Name
Clinical Title
Institution
Street Address
City
State
Zip Code
Country
Fax Number
Phone
Email (Note: Paperwork for testing, including requisition and specimen kit ordering instructions, will be sent to this email following approval of application.)
Yes, I would like to be added to PPMD's email marketing list.
SPECIMEN COLLECTION KITS
The following types of kits are available from Revvity Omics:
Blood
Dried Blood Spot cards
Saliva
Saliva kits can be shipped directly to a patient's home, but the ordering provider must request the kit directly on the Revvity website, and must first upload the completed requisition. Directions for ordering kits will be sent via secure email or fax with the requisition attached.
Is this patient currently in clinic or coming into clinic today? (If yes, we will send the requisition today, assuming we receive application between 8-5 ET M-F.)
Please Confirm That This Participant:
I attest that my patient is:
A citizen or resident of the United States or Canada
I attest that my patient is....
Since carrier or familial variant testing is being requested, please enter information regarding patient's affected relative including: Name, relationship to patient, date of testing, and DMD variant identified
Have you used Decode Duchenne in the past?
Others questions or comments:
I attest that I am a healthcare provider (physician/nurse/genetic counselor) directly involved in the evaluation and treatment of this patient. I attest that the information provided on this application is true, accurate and complete to the best of my knowledge and I understand that I am liable for any falsification or omission of information.
De-identified data from the Decode Duchenne program may be shared with industry sponsors, including founding sponsor Sarepta Therapeutics and other industry sponsors. This de-identified data may be used for diagnostic and therapeutic disease research, such as understanding the incidence of certain dystrophin gene variants, evaluating and improving the diagnosis of Duchenne/Becker, and developing novel variant-specific therapeutic strategies.
Submit
Fields marked with an asterisk (*) are required.