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Clinical sample submission for DSRT
Information about the person submitting the form
Your name (first, last)
Your email
?
"You will receive a confirmation of your submission to this address."
Copy to (email address)
?
"Who else should be notified about the submission in your group? This is typically your supervisor or lab manager keeping track of sample submissions."
Billing information
Organisation name
Contact email for billing
Invoicing address
Additional address line
City
Postal code
Country
Business ID / VAT / Y-tunnus
E-invoicing operator name
E-invoicing operator number
E-invoicing address (OVT number)
Billing reference number (e.g. wbs code)
Project ID for billing
Additional invoicing
Yes
No
Include mononuclear cells and DSRT preparation in the invoice?
Sample information
Long sample ID
Short sample ID
Project name
Sample type
--Select--
does not apply
Diagnostic
Relapsed
Refractory
Secondary
Healthy control
Primary
Histotype
--Select--
not determined
Acute myeloid leukemia (AML)
Multiple Myeloma (MM)
Myelodysplastic syndromes (MDS)
Chronic myelogenous leukemia (CML)
Chronic myelomonocytic leukemia (CMML)
Acute lymphoblastic leukemia (ALL)
B-cell acute lymphoblastic leukemia (ALL)
Pre-B acute lymphoblastic leukemia (ALL)
T-cell acute lymphoblastic leukemia (ALL)
Diffuse large B-cell lymphoma
mixed phenotype leukemia (MPAL)
plasma cell leukemia (PCL)
Bone marrow
Additional sample description (optional)
Cell viability at submission (%)
Work requested
Flow cytometry
Yes
No
Use flow cytometry?
Additional libraries
Yes
No
Use more than 1 drug library?
Number of different drug sets to use
Drug set 1
Drug library 1
--Select--
FO5A
FM1B
FM1B plate 1 only
FA2D
QA1 (for Prson)
QA1B (flow)
Custom drugs
Chestnut MM06
Chestnut MM07
Chestnut AML
DN-06
DN-combo01
DN-combo02
Other
Readout for library 1
--Select--
CTG & CTxG
Flow Cytometry
Real Time Glow (RTG)
CellTiterGlow (CTG) only
CellToxGreen (CTxG) only
Number of cells (in millions)
Sample volume (ml)
Media
--Select--
12,5% conditioned media
25% conditioned media
MCM
other
(other)
Time of adding drugs
Use standard plates with pre-plated drugs
On day 1 after cell seeding
other
Incubation time (days)
Additional information about drug libraries and treatment
Drug set 2
Drug library 2
Does not apply
FO5A
FM1B
FM1B plate 1 only
FA2D
QA1 (for Prson)
QA1B (flow)
Custom drugs
Chestnut MM06
Chestnut MM07
Chestnut AML
DN-06
DN-combo01
DN-combo02
Other
Readout for library 2
CTG & CTxG
Flow Cytometry
Real Time Glow (RTG)
CellTiterGlow (CTG) only
CellToxGreen (CTxG) only
Does not apply
Number of cells (in millions)
Sample volume (ml)
Media
12,5% conditioned media
25% conditioned media
MCM
other
Does not apply
(other)
Time of adding drugs
Use standard plates with pre-plated drugs
On day 1 after cell seeding
other
Does not apply
Incubation time (days)
Additional information about drug libraries and treatment
Drug set 3
Drug library 3
FO5A
FM1B
FM1B plate 1 only
FA2D
QA1 (for Prson)
QA1B (flow)
Custom drugs
Chestnut MM06
Chestnut MM07
Chestnut AML
DN-06
DN-combo01
DN-combo02
Other
Does not apply
Readout for library 3
CTG & CTxG
Flow Cytometry
Real Time Glow (RTG)
CellTiterGlow (CTG) only
CellToxGreen (CTxG) only
Does not apply
Number of cells (in millions)
Sample volume (ml)
Media
12,5% conditioned media
25% conditioned media
MCM
other
Does not apply
(other)
Time of adding drugs
Use standard plates with pre-plated drugs
On day 1 after cell seeding
other
Does not apply
Incubation time (days)
Additional information about drug libraries and treatment
Miscellaneous
Optional additional notes
Partial submission
I wish to save the form and continue using the link that will be sent into email I give
Email address
Proceed
