• 09309181270

فرم تحویل نمونه(الیزا، مولکولی ،استرس اکسیداتیو، کشت سلولی)

فرم تحویل نمونه

 

مشخصات در خواست کننده

نام و نام خانوادگی: ...............................................................                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

رشته تحصیلی یا فعالیت: ......................................................

مشخصات نمونه :...................................................................

نوع نمونه:            پلاسما£                            سرم£               مایع رویی کشت سلول£                                                                                                                          

                         بزاق   £                           ادرار£              سایر£    

تعداد کل نمونه:....................................................................

در صورتی که گزینه سایر را پر کرده اید ، لطفا نام ببرید ............................................................................

منبع نمونه:           انسانی £                     موشی £           رت £

در صورتیکه دو نوع نمونه انسانی و موشی همزمان مورد درخواست باشد لطفا برای هر کدام فرم جداگانه

تکمیل فرمایید.

موضوع یا زمینه تحقیق:........................................................................................................................................

 

سایر توضیحات (در صورت نیاز) :

 

امضای تحویل دهنده                                                                   امضای تحویل گیرنده

نام و نام خانوادگی                                                                     نام و نام خانوادگی

تاریخ                                                                                       تاریخ    

ردیف

نوع نمونه

شماره ها و یا مشخصات نمونه

تعداد نمونه

سایتوکاین مورد سنجش