Download Ventricular Arrhythmia and Sudden Death without Structural Heart

+34 881 60 00 03
[email protected]
www.healthincode.com
Request for genetic study
Ventricular Arrhythmia and Sudden Death without Structural Heart Disease General Panel
1
Patient ID and sample information
Patient ID
Name and/or ID code
Blood
Sample reference
Peripheral blood from 3 to 5 ml in EDTA tubes
Saliva
Using the indicated saliva kit
DNA*
Please write the same reference on the sample tube
at least 5 µg and concentration > 50 ng/µl
*Specify origin DNA:
Blood, frozen blood, saliva, fresh tissue, frozen tissue, paraffin tissue, etc.:
2
Genetic study requested
General NGS panel
Ventricular Arrhythmia and Sudden Death without Structural Heart Disease
Long QT syndrome, short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia and cardiomyopathies
CACNA1C
CASQ2
DES
DSC2
DSG2
DSP
FLNC
3
JUP
KCNE1
KCNE2
KCNH2
KCNJ2
KCNJ8
KCNQ1
LMNA
PKP2
PLN
PRKAG2
RYR2
SCN1B
SCN5A
TMEM43
TNNC1
TNNI3
TNNT2
ABCC9
ACTC1
AKAP9
ANK2
CACNA1D
CACNA2D1
CACNB2
CALM1
CALM2
CALM3
CAV3
EMD
FGF12
FHL2
GAA
GJA5
GLA
GPD1L
HCN4
HFE
KCND2
KCND3
KCNE5
KCNE3
KCNJ5
KCNK17
LAMP2
MURC
NKX2-5
RANGRF
SCN10A
SCN2B
SCN3B
SCN4B
SLMAP
SNTA1
TBX5
TNNI3K
TRDN
TRPM4
TTR
ANK3*
IRX3*
KCNA5*
LDB3*
77 genes
MYH6*
MYH7*
NOS1AP*
NPPA*
PTRF*
SYNE1*
SYNE2*
Clinical data
*A clinical report is strongly recommended
All personal information provided on this form, as well as subsequent diagnosis, research, and/or statistical information, will be treated in strict confidentiality and under the protection of and in line with
specifications set forth in Organic Law 15/1999 of 13 December on the Protection of Personal Data (LOPD), and will be included in the files “CARDIOREGISTER”, “HIC MUTACIONES”, and “LIMS”, duly
registered with the Spanish Data Protection Agency and whose purpose is the analysis and diagnosis of heart diseases. Please note that you are entitled to access the file and to modify and delete your
data, and you may exercise said rights by sending a written request to the entity Health in Code at Edificio El Fortín, As Xubias, s/n, 15006 A Coruña, Spain, with the reference: “Data Protection”, attaching
a copy of your National Identification Card.
07/2016
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4
Requesting physician’s information
Full name
Hospital/Medical center
Address
City
Province / Region / State
Country
Phone
Email
Zip code
*The results will be sent to the provided e-mail address, digitally signed in PDF© format via certified electronic mail
Petitioner’s signature
Date
5
Information for invoice
Send invoice to
Indicate department or person responsible
Tax Id/
VATIN
Address
City
Province / Region / State
Country
Phone
Email
Zip code
*If orders have been made on previous occasions and the invoicing information has not changed, this section can be omitted.
6
Statement of the existence of informed consent
The patient identified in this request (or his/her legal representative) is aware of the information included in it and authorizes
the performance of this genetic study.
It is possible to obtain unexpected information during the sample analysis process, which the patient identified in this
request (or his/her legal representative) has decided that he/she wishes to be informed about.
In addition, the patient identified in this request (or his/her legal representative) authorizes Health in Code S.L. to store the
current biological sample for subsequent studies and/or confirmation tests.
The patient identified in this request (or his/her legal representative) also authorizes Health in Code S.L. to use the current
biological sample for research purposes approved by the relevant ethical committee, always maintaining the patient’s
anonymity.
Physician’s signature
Date
All personal information provided on this form, as well as subsequent diagnosis, research, and/or statistical information, will be treated in strict confidentiality and under the protection of and in line with
specifications set forth in Organic Law 15/1999 of 13 December on the Protection of Personal Data (LOPD), and will be included in the files “CARDIOREGISTER”, “HIC MUTACIONES”, and “LIMS”, duly
registered with the Spanish Data Protection Agency and whose purpose is the analysis and diagnosis of heart diseases. Please note that you are entitled to access the file and to modify and delete your
data, and you may exercise said rights by sending a written request to the entity Health in Code at Edificio El Fortín, As Xubias, s/n, 15006 A Coruña, Spain, with the reference: “Data Protection”, attaching
a copy of your National Identification Card.
07/2016
www.healthincode.com
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7
Sample requirements
You should send the sample/s following the adequate procedure. All samples must be accompanied by a copy of this form.
This information is essential to provide patient information and identity the test/s to be carried out.
Sample collection and transportation are under client´s responsability. However, we recommend to follow the guidelines below to
ensure samples arrival upon quality and quantity requisites that guarantee optimal analytic processing.
· How should samples be collected?
· How should samples be packaged?
Genomic DNA
Infectious substances
Minimum amount for NGS >5-10 μg (A260/280 = 1.8-1.9) and for
Sanger sequencing >1 μg (A260/280 = 1.8-1.9); shipped at 4-8ºC
(recom­mended) or at room temperature (in this case the sample
must be in our lab within 24/48 hours).
Saliva sample
Saliva kit shipped at room temperature. Kits can be ordered at
[email protected].
Whole blood
3 to 5 ml of whole blood in EDTA in one lavander/purple top tube
shipped at 4-8ºC (recommended) or at room temperature (in this
case the sample must be in our Lab within 24/48 hours).
Other sample
If you want to send another kind of sample, please contact our
team at [email protected]
Triple layer
Package the sample using the triple layer system of packaging
according the standards of the World Health Organization (WHO)
and the International Air Transport Association (IATA) detailed in
the documents area of our website www.healthincode.com.
Primary receptacle: watertight, leak-proof
receptacle containing the specimen.
Secondary packaging: watertight. Absorbent
material must be used to cushion primary
receptacles.
Outer packaging: minimum size 100×100mm.
Rigid container.
I do not have triple layer
If you do not have proper packaging, please contact our team at
[email protected] or +34 881 600 003.
Non-Infectious substances (Saliva)
· Where to send samples?
Send the package to the following address (contact us for any
questions regarding shipping at [email protected]):
Non-infectious or exempt substances, do not require triple layer.
Indicate “EXEMPT HUMAN SPECIMEN” on the sample outer
packaging.
HEALTH IN CODE S. L.
(Att. Laboratory)
Edificio El Fortín
As Xubias, s/n
15006 A Coruña, Spain
Contact us with any questions or for additional information:
Telephone: Fax: Contact:
Clinical team:
+34 881 600 003
+34 981 167 093
[email protected]
[email protected]
Tel.: +34 881 60 00 03 · Fax: +34 981 16 70 93
www.healthincode.com
All personal information provided on this form, as well as subsequent diagnosis, research, and/or statistical information, will be treated in strict confidentiality and under the protection of and in line with
specifications set forth in Organic Law 15/1999 of 13 December on the Protection of Personal Data (LOPD), and will be included in the files “CARDIOREGISTER”, “HIC MUTACIONES”, and “LIMS”, duly
registered with the Spanish Data Protection Agency and whose purpose is the analysis and diagnosis of heart diseases. Please note that you are entitled to access the file and to modify and delete your
data, and you may exercise said rights by sending a written request to the entity Health in Code at Edificio El Fortín, As Xubias, s/n, 15006 A Coruña, Spain, with the reference: “Data Protection”, attaching
a copy of your National Identification Card.
07/2016
www.healthincode.com
3/3