Download GENETIC TESTING REQUISITION Please ship

GENETIC TESTING REQUISITION
1-844-363-4357· [email protected]
Schillingallee 68 · 18057 Rostock Germany
Attention Patient: Please visit your nearest LifeLabs or CML Healthcare Patient Service Centre for sample collection
CONTRACT #
LL: K012-01/ CML: CEN
Report to Physician Billing #
LifeLabs Demographic
Label
Ordering Physician Name
Physician Signature:
Ordering Physician
Address & Contact Info:
Copy to (name & contact
Address:
Tel:
Fax:
info):
Name:
Contact:
Bill to
Contract # K012-01 (patient does not pay at time of collection)
Patient Gender: (M/F)
Patient DOB: (YYYY/MM/DD)
Patient Name (Last, First):
Patient Address:
Patient Health Card:
Patient Telephone:
Please ship all NON-PRENATAL samples to:
LifeLabs · Attn CDS Department • 100 International Boulevard• Toronto ON• M9W6J6
TEST REQUESTED
LL TR # / CML TC#
□ Genetic Test - Blood Sample 2 x 4mL EDTA
□ Genetic Test (Pediatric) - Blood Sample 1 x 2mL EDTA
□ Genetic Test - Other Sample Type
4005
4008
4014
PRENATAL SAMPLES: Please ship directly to CENTOGENE.
Date Blood Collected (YYYY/MM/DD): ___________ Time Blood Collected (HH:MM)) :________ Collector Name: ___________________
GENETIC TESTING CONSENT
I understand that a DNA specimen will be sent to LifeLabs for genetic testing. My physician has told me about the condition(s) being tested and its genetic basis. I
am aware that correct information about the relationships between my family members is important. I agree that my specimen and personal health information
may be sent to Centogene AG at their lab in Germany (address below). To ensure accurate testing, I agree that the results of any genetic testing that I have had
previously completed by Centogene AG may be shared with LifeLabs. I understand that LifeLabs will contact me for a new specimen if a test result cannot be
provided from the original specimen. I agree that a copy of my results will be sent to my ordering physician. I further agree that for any test(s) performed by
Centogene AG, a copy of my results will also be sent to LifeLabs. I understand that once the requested test(s) has/have been completed, any remaining sample
will be stored at the testing laboratory.
OPTIONAL CONSENT : Please Initial where appropriate
_____ I agree that my de-identified sample may be used for product development or research purposes. I understand that I will not receive any royalties, resultant
payments, benefits or rights to products or discoveries.
_____ I do not want my remaining sample to be stored. Please destroy any remaining sample once the final report has been issued.
_____ I have had genetic testing completed in the past by the following laboratories: ___________________________________________________________________________
I agree that Centogene AG and LifeLabs may obtain a copy of these genetic test results from the testing laboratory.
Patient/Substitute Decision Maker: Signature: ___________________________________________________; Date: _______________________________________________________
Printed name: ________________________________________________; Relationship to person being tested: _________________________
OR: I certify that verbal consent was obtained from the patient /substitute decision maker for the requested genetic testing
Signature: ___________________________________________________; Date: _______________________________________________________
** LIFELABS/CML STAFF: PHOTOCOPY REQUISITION AND INCLUDE 1 COPY WITH SAMPLES**
Page 1/4
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V3 Jan2015
GENETIC TESTING REQUISITION
REPRODUCTIVE HEALTH & INFERTILITY
1-844-363-4357· [email protected]
Schillingallee 68 · 18057 Rostock Germany
Patient Name:
Sample Type:
Patient DOB (YYYY/MM/DD):
□ *Blood (EDTA: 5mL for single gene, 10mL for panel)
□ DNA (single gene:1-10ug, panel 10-100ug)
□ *Filter card (1 card/30 exons: Available by request)
□ Saliva (Oragene OG-510: Available by request)
□ Fibroblast/Skin Biopsy (0.5cm )
□ Cultured cells (1 flask, min 25cm , 80-90% confluent)
□ **Amniotic fluid (10mL)
□ **Chorionic Villus (10 villi, cleaned)
□ Other: _________________________________________________________
LifeLabs Demographic
Label
2
2
* Exact amount depends on size of panel, see www.centogene.com
** Please contact us prior to sending cells
Billing Status:
Institution Billing ONLY:
□ Ministry of Health Approved (Approval letter attached)
□ Institution (Complete information below)
□ Ministry of Health Approval Pending
□ Private Pay (Complete information below)
Institution Name: ___________________________________ Contact Name: _____________________________
Address:
Phone: (
Private Pay ONLY:
)
Credit Card Type:
-
Fax: (
)
□ MasterCard
-
Email: _______________________________
□ Visa
Card Number_________________________________________ Exp Date(MM/YY)_____________________
Name (as it appears on credit card)__________________________________________________________
I understand that my credit card will be charged for the full amount of testing not paid for by my
provincial health plan
Cardholder Signature: _______________________________________ Date (DD/MM/YYYY)________________
Patient Information:
Gender:
□M □ F
Ethnicity: ___________________________
Additional patient medical information:
Relevant Family history:
Have other family members submitted samples to Centogene for analysis? □Y
If yes, Name:_______________________
□N
Relationship to patient _________________________
DOB (YYYY/MM/DD):____________________
Familial Mutation Testing
Gene:______________ Mutation (HGVS):_____________________
□Familial Report attached
Testing Instructions:
(ex: Reflex order)
** PLEASE INCLUDE A COPY OF REQUISITION WITH SAMPLES **
Page 2/4
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V3 Jan2015
GENETIC TESTING REQUISITION
REPRODUCTIVE HEALTH & INFERTILITY
1-844-363-4357· [email protected]
Schillingallee 68 · 18057 Rostock Germany
Patient Name:
Patient DOB (YYYY/MM/DD):
Please indicate requests for Hot Spot (H), Exon (E), Sequencing (S), Repeat Expansion (R) and/or Deletion/Duplication (D) analysis
Infertility : Tests for Males & Females
Microarray:
S
Genomic microarray
NGS Panels:
D
S
D
S
Infertility panel
Kallmann syndrome panel
(LHB, FSHB, LHCGR, FSHR)
(CHD7, FGFR1, FGF8, GNRHR, GNRH1, KAL1, KISS1R, PROK2, PROKR2, SEMA3A, TAC3, Colorectal canceTACR3)
Single genes:
D
D
D
D
D
D
D
D
D
D
D
S
S
S
S
S
S
S
S
S
S
S
Androgen insensitivity (AR)
Aromatase deficiency (CYP19A1)
Disorders of sex development with cleft palate (FOXF2)
Follicle-stimulating hormone deficiency, isolated (FSHB)
Hydatidiform mole (NLRP7)
Hydatidiform mole (KHDC3L)
Hypogonadotropic hypogonadism (KISS1)
Hypogonadotropic hypogonadism (KISS1R)
Hypogonadotropic hypogonadism (LHB)
Hypogonadotropic hypogonadism (NSMF)
Hypogonadotropic hypogonadism 7 with or without anosmia (GNRHR)
D
D
D
D
D
D
D
D
D
D
D
S
S
S
S
S
S
S
S
S
S
S
Hypogonadotropic hypogonadism 11 with or without anosmia (TACR3)
Hypogonadotropic hypogonadism 12 with or without anosmia (GNRH1)
Hypogonadotropic hypogonadism type 14 (WDR11)
Kallmann syndrome type 1 (KAL1)
Kallmann syndrome type 2 (FGFR1)
Kallmann syndrome type 3 (PROKR2)
Kallmann syndrome type 4 (PROK2)
Kallmann syndrome type 5 (CHD7)
Kallmann syndrome type 6 (FGF8)
Kallmann syndrome, SEMA3A related (SEMA3A)
Leydig cell hypoplasia type 1 (LHCGR)
D
D
D
D
D
D
D
D
D
S
S
S
S
S
S
S
S
S
Spermatogenesis dysfunction (SOHLH1)
Oligozoospermia and/or tetratazoospermia(FSHR)
Oligo-astheno-teratozoospermia (NANOS1)
Spermatogenic failure type 4 (SYCP3)
Spermatogenic failure type 5 (AURKC)
Spermatogenic failure type 6 (SPATA16)
Spermatogenic failure type 7 (CATSPER1)
Spermatogenic failure type 8 (NR5A1)
Spermatogenic failure type 9 (DPY19L2)
R
D
S
Premature ovarian failure/Fragile X Syndrome (FMR1)
H
H
D
D
S
S
Noonan syndrome type 6 (NRAS)
Noonan syndrome type 7 (BRAF)
Noonan syndrome-like disorder with or without juvenile meylomonocytic
leukemia (CBL)
Polycystic kidney disease type 1, autosomal recessive (PKHD1)
Polycystic kidney disease type 1, autosomal dominant (PKD1)
Polycystic kidney disease type 2, autosomal dominant (PKD2)
Usher syndrome type 1D/F (PCDH15)
Usher syndrome type 1D/F (CDH23)
Usher syndrome type 3A (CLRN1)
Usher syndrome type IJ (CIB2)
Infertility : Tests for Males*
Single genes:
H
D
D
D
D
D
D
D
D
D
S
S
S
S
S
S
S
S
46XX sex reversal 1 (SRY)
Autosomal nonsyndromic male infertility (CATSPER2)
Azoospermia induced by Y chromosome microdeletions (AZF region)
Cystic fibrosis/Congenital Bilateral Absence of the Vas Deferens (CFTR)
Deafness and male infertility (STRC)
Oligo-astheno-teratozoospermia (NANOS1)
Persistent mullerian duct syndrome type 1 (AMH)
Persistent mullerian duct syndrome type 2 (AMHR2)
Pseudohermaphroditism with gynecomastia (HSD17B3)
*Gender is based on phenotype which may not be consistent with a patient’s genotypic gender
Infertility: Tests for Females*
Single genes:
D
D
S
S
Ovarian dysgenesis 1 (FSHR)
Oogenesis dysfunction (SOHLH1)
*Gender is based on phenotype which may not be consistent with a patient’s genotypic gender
Additional Genetic Syndromes with Infertility
NGS Panels:
D
S
Polycystic kidney panel
(BICC1, PKD1, PKD2, NOTCH2, PKHD1)
Single genes:
E
E
D
D
S
S
Adrenal hypoplasia (NR0B1)
Denys-Drash syndrome (WT1)
D
S
Frasier syndrome (WT1)
D
S
D
R
R
D
D
D
D
S
Myotonic dystrophy type 1 (DMPK)
Myotonic dystrophy type 2 (CNBP)
Noonan syndrome like (SHOC2)
Noonan syndrome type 1 (PTPN11)
Noonan syndrome type 3 (KRAS)
Noonan syndrome type 4 (SOS1)
Noonan syndrome type 5 (RAF1)
D
D
D
D
D
D
D
S
S
S
S
S
S
S
S
S
S
S
H
H
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The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V3 Jan2015
GENETIC TESTING REQUISITION
REPRODUCTIVE HEALTH & INFERTILITY
1-844-363-4357· [email protected]
Schillingallee 68 · 18057 Rostock Germany
Patient Name:
Patient DOB (YYYY/MM/DD):
Population Screening Tests
NGS Panels:
Advanced Ashkenazi (Sanger) panel
S
*includes BRCA1/BRCA2 analysis. To opt out,
please indicated in the “Test Instructions”
GBA (8 mut), CFTR (26 mut), HEXA (7mut), IKBKAP (2 mut), ASPA (4 mut), G6PC (2 mut) ABCC8 (2 mut), MCOLN1 (2 mut), BCKDHB
(3mut), FANCC (2 mut), DLD (2 mut), SMPD1 (4 mut), CLRN1 (1 mut), PCDH15 (1mut), BLM (1mut), NEB (1 mut), BRCA1 (2 mut),
BRCA2 (1 mut)
S
Basic Ashkenazi (Sanger) panel
(HEXA (7 mutations), IKBKAP (2 mut), ASPA (4 mut),MCOLN1 (2 mut), FANCC (2 mut), SMPD1 (4 mut), BLM (1 mut))
Single genes:
D
D
D
S
S
S
Cystic fibrosis (CFTR)
Hemochromatosis classical (HFE)
Sickle cell anemia (HBB)
D
D
D
D
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S
S
S
S
Thalassemia, alpha (HBA1)
Thalassemia, alpha (HBA2)
Thalassemia, delta-beta (HBB)
Spinal muscular atrophy (SMA) (SMN1)
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V3 Jan2015