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GRC
Forms Folder
Amended: 06/04/14
Printed: 6/4/17
Send by express courier:
Attention: Clinic Manager
GENOMICS RESEARCH CENTRE (GRC) Clinic
Institute for Health and Biomedical Innovation
Queensland University of Technology
5 School Street (Loading Bay)
Kelvin Grove 4059, Brisbane, Queensland
Diagnostic Request Information
Version 2.2
Authorised: R. Smith
Patient ID
Last name:…………………………………………………
First name:
……………………………………………
Address:……………………………………………………
Phone: ………………….. Mobile:……………………….
Ph: 07 313 80970 OR 07 313 80970
Fax: 07 313 86039
Send samples with an ice brick, same day OR overnight
Test Requested:
 NEXT-GEN SEQUENCING (Combined test for FHM1,
FHM2, FHM3 EA2, CADASIL and SCA6. All genes, all
D.O.B (dd/mm/yy) ____/____/____ Sex M
F
Billing Status
Please indicate the name of the person or Department
to receive the account:
major exons)
 NEXT-GEN SEQUENCING (Whole Exome Sequencing)
Specify Genes or Disorders:________________________
Note: There is NO MEDICARE REBATE for these
tests.
_______________________________________________
 KNOWN MUTATION (Previously identified mutation in
tested gene in other family member. Specify gene with
request)
 MTHFR (C677T SNP)
Purpose of test:
Genetic Counselling
 Confirm Clinical Diagnosis
Has the individual been offered counseling?
 Carrier Status



 Family Study
 For Research
 Bank DNA until further notice
Consent to testing
 Family/pedigree information
Has a Consent Form for Specialised/DNA Testing
been completed?  Yes
 No
 Other, Specify:
Sample Requisition:
Family Information
Collection By:
Have samples from this family been sent to the GRC
Date (dd/mm/yy) _____/_____/_____
for testing before? 
Time (hh:mm)____/_____
Specify Name: ………………………………….
Country of birth: ………………………………...
Ethnic background: …………………………….
Is patient the index case? 

Blood
EDTA _____ mL
Lithium Heparin _____ mL

Specify Name of Index:
D.O.B (dd/mm/yy) _____/_____/_____
Other
DNA (Conc & stored in) __________ & __________
Copy of report to:
Name: ……………………………………
Initials: ………
Relationship to this patient: …………………………
Test requested by:
Name:………………………………
Initials: ……….
Address:………………………………………………………
Address: …………………………………………………
…………………………………………………………………
…………………………………………………………….
…………………………………………………………………
…………………………………………………………….
Phone: …………………………..
Phone: ……………………… Provider #: …………….
Provider #: …………
Signature:………………………………………………….
\Forms Folder\GRC Diagnostic Request Information v2.2.doc
Page 1 of 5
GRC
Forms Folder
Amended: 06/04/14
Printed: 6/4/17
Diagnostic Request Information
Version 2.2
Authorised: R. Smith
Clinical Notes:
Specimen Collection Protocol for Diagnostic Testing


5mls of whole EDTA blood or 5mls of blood in Lithium Heparin is
required for genetic testing. This must be packed in ice for transport.
Or
The DNA extracted from 10mls of blood collected in EDTA or lithium
heparin. Please indicate whether the DNA is stored in TE or water
and which extraction method was used. Please ensure that 260/280
ratios are 1.6-2.1 and 260/230 ratios are 1.7-2.3 for purified DNA

Please Note: any specimens arriving at GRC after seven (7) days will
be rejected and a recollection is required.

All tests take approximately six (6) to eight (8) weeks from time of
receipt of blood.

Due to the nature of Class B or predictive tests, could you please
ensure that the patient receives pre- and post- counselling and that
written consent has been obtained. Clinic Genetics Services can
be located on the HGSA website http://www.hgsa.com.au

All diagnostic tests have been listed on the HGSA website, but are
not as yet Medicare rebateable.
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GRC
Forms Folder
Amended: 06/04/14
Printed: 6/4/17
Diagnostic Request Information
Version 2.2
Authorised: R. Smith
Request Form Requirements
The request form must contain the items highlighted in bold, other
information is optional:
 Patients First and Surname
 Patients Date of Birth
 Patients Sex
 Patients Address
 Medicare Number
 Ward and hospital if inpatient
 Requesting Doctors Name
 Requesting Doctors Address
 Provider Number
 Doctors Signature
 Tests Requested
 Date of request
 Clinical Notes
 Names and addresses of copy doctors
 Date and Time of collection
 Identity of Specimen Collector
 Type of specimen, amount and containers collected
 Billing arrangements
GRC Diagnostic Testing Service
Diseases Tested
Familial Hemiplegic Migraine (FHM1)
Familial Hemiplegic Migraine (FHM2)
Familial Hemiplegic Migraine (FHM3)
Episodic Ataxia Type 2 (EA2)
CADASIL
SCA6
Next Generation Sequencing – Combined test for FHM1, FHM2, FHM3,
EA2, CADASIL and SCA6.
CACNA1A gene - Exons 1-41, 5’UTR, 3’UTR. (partial Ex 1, 29, Int 11, 20, 25, 3’UTR)
ATP1A2 gene - Exons 1-23, 5’UTR, 3’UTR (partial coverage for Ex 8, 3’UTR)
SCN1A gene – Exons 1-27, 5’UTR, 3’UTR (partial coverage for 5’UTR, Ex 2, 6, 15, 16, 18,
Int 21)
Notch 3 gene - Exons 1-33, 5’UTR, 3’UTR (partial coverage for Ex 10, 30, 31, 3’UTR)
TRESK gene – Exons 1-3, 5’UTR, 3’UTR (complete coverage)
Next Generation Sequencing – Whole Exome Sequencing. Disease
and/or genes to be specified
MTHFR
MTHFR gene – C677T Polymorphism
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GRC
Forms Folder
Amended: 06/04/14
Printed: 6/4/17
Diagnostic Request Information
Version 2.2
Authorised: R. Smith
Specimens Labeling Requirements:
All specimens should be labeled with:
The patient’s first name, surname, date of birth, date and time of
collection, the patient’s signature and collector’s initials
Minimum specimen requirements
First name, Surname with date of birth and collection date
 Courier Details:
To avoid rejection, samples must be packed on ice and sent by courier
the same day, or overnight, and addressed to:
ATTENTION:
GENOMICS RESEARCH CENTRE (GRC) Clinic
Institute for Health and Biomedical Innovation
Queensland University of Technology
5 School Street (Loading Bay)
Kelvin Grove 4059, Brisbane, Queensland
Ph: 07 313 80970 OR 07 313 80970
Fax: 07 313 86039
Availability of Clinical Advice
The laboratory may give advice on the nature of any mutations
identified and their likely effect on protein production. Where
information is available in the scientific literature, some clinical advice
regarding the nature of genetic variations can also be given.
Protection of Personal Information
The Genomics Research Centre is committed to protecting the
personal identification of the patients it serves. Thus, personal
information, including the discussion of results will only take place with
the patient themselves, clinicians authorised on the initial request, or
those subsequently authorised by the patient or authorised clinicians.
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GRC
Forms Folder
Amended: 06/04/14
Printed: 6/4/17
Diagnostic Request Information
Version 2.2
Authorised: R. Smith
Complaints and Questions
If there are complaints or questions about the laboratory’s tests or
procedures, please contact the Quality Manager at (07) 313 80970 or
[email protected] Complaints will be handled according to a
standard procedure by which they are recorded and necessary
actions to remedy them implemented following consultation with staff
and clinic management as to the causes of the problem.
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