Download PATIENT NAME: NEXT-GENERATION DNA SEQUENCING TEST

NEXT-GENERATION
DNA SEQUENCING
TEST REQUEST FORM
5424 Glenridge Drive NE
Atlanta, GA 30342 USA
toll-free: 844.TESTMNG
fax: 678.225.0212
mnglabs.com
No Sunday or Holiday Deliveries Accepted | CLIA License #11D0703390; State of Georgia License #060-381
PATIENT NAME:
NEUROLOGIC DISORDERS
COGNITIVE/NEUROBEHAVIORAL
INTELLECTUAL DISABILITY/AUTISM PANELS
 (NGS325) INTELLECTUAL DISABILITY, COMPREHENSIVE;
349 GENES
 (NGS349) INTELLECTUAL DISABILITY, NONSYNDROMIC;
81 GENES
 (NGS350) INTELLECTUAL DISABILITY; SYNDROMIC; 221
GENES
 (NGS398) MACROCEPHALY & OVERGROWTH
SYNDROMES; 15 GENES
DEMENTIA PANELS
 (NGS356) ALZHEIMER DISEASE/FRONTOTEMPORAL
DEMENTIA; 49 GENES
 (NGS406) ALZHEIMER DISEASE/FRONTOTEMPORAL
DEMENTIA; 49 GENES + C9ORF72 REPEAT EXPANSION
ANALYSIS
 (NGS380) AMYLOID RELATED DISORDERS; 18 GENES
 (NGS376) DEMENTIA, COMPREHENSIVE; 91 GENES
 (NGS407) DEMENTIA, COMPREHENSIVE (91 GENES) +
C9ORF72 REPEAT EXPANSION ANALYSIS
 (NGS410) DEMENTIA, COMPREHENSIVE; 91 GENES+
HTT REPEAT EXPANSION ANALYSIS
 (NGS411) DEMENTIA, COMPREHENSIVE (91 GENES) +
C9ORF72 REPEAT EXPANSION ANALYSIS+ HTT REPEAT
EXPANSION ANALYSIS
CENTRAL HYPOVENTILATION
 (NGS371) CENTRAL HYPOVENTILATION; 7 GENES
EPILEPSY
 (NGS385**) EPILEPSY, COMPREHENSIVE; 165 GENES
 (NGS386) EPILEPTIC ENCEPHALOPATHY; 77 GENES
 (NGS412) MYOCLONIC EPILEPSY; 34 GENES
LEUKODYSTROPHY/LEUKOENCEPHALOPATHY/
HYPOMYELINATION
 (NGS372**) COMPREHENSIVE; 102 GENES
 (NGS373) NON-MITOCHONDRIAL; 53 GENES
 (NGS374**) MITOCHONDRIAL; 45 GENES
 (NGS375) VANISHING WHITE MATTER,
DYSMYELINATING, & HYPOMYELINATING
LEUKODYSTROPHY; 62 GENES
MOVEMENT DISORDERS/DYSTONIA/ATAXIA
ATAXIA/EPISODIC ATAXIA PANEL
 (NGS324**) ATAXIA/EPISODIC ATAXIA; 117 GENES
 (NGS408**) ATAXIA/EPISODIC ATAXIA; 117 GENES +
HTT REPEAT EXPANSION ANALYSIS
BRAIN CALCIFICATION PANEL
 (NGS360) BASAL GANGLIA CALCIFICATION; 20 GENES
BRAIN IRON ACCUMULATION PANEL
 (NGS362) NEURODEGENERATION WITH BRAIN IRON
ACCUMULATION; 10 GENES
DYSTONIA PANELS
 (NGS358**) DYSTONIA, COMPREHENSIVE; 96 GENES
 (NGS409**) DYSTONIA, COMPREHENSIVE; 96 GENES +
HTT REPEAT EXPANSION ANALYSIS
 (NGS359) PRIMARY DYSTONIA SYNDROME; 18 GENES
 (NGS361**) DYSTONIA, OXPHOS DEFECTS; 22 GENES
PARKINSON DISEASE/PARKINSONISM PANELS
 (NGS357) PARKINSON DISEASE; 75 GENES
NEUROCHEMISTRY
 (NGS344) AICARDI- GOUTIERES SYNDROMES; 6 GENES
 (NGS315) NEUROTRANSMITTER METABOLISM; 101
GENES
 (NGS315L) NEUROTRANSMITTER METABOLISM; 127
GENES
 (NGS316) DOPAMINE METABOLISM; 16 GENES
 (NGS310) GABA METABOLISM; 30 GENES
 (NGS317) SEROTONIN METABOLISM; 28 GENES
DOB:
 (NGS318) TETRAHYDROFOLATE METABOLISM; 12
GENES
 (NGS320) TYROSINEMIA; 4 GENES
NEUROFIBROMATOSIS
 (NGS335) NEUROFIBROMATOSIS DISORDERS; 21
GENES
NEUROMUSCULAR
FETAL AKINESIA/ARTHROGRYPOSIS PANEL
 (NGS348) FETAL AKINESIA/ ARTHROGRYPOSIS; 153
GENES
MOTOR NEURON DISEASE PANELS
 (NGS323) AMYOTROPHIC LATERAL SCLEROSIS; 27
GENES
 (NGS405) AMYOTROPHIC LATERAL SCLEROSIS; 27
GENES + C9ORF72 REPEAT EXPANSION ANALYSIS
 (NGS347) SPINAL MUSCLE ATROPHY; 17 GENES
MYOPATHY/MUSCULAR DYSTROPHY [MD] PANELS
 (NGS332) HYPOKALEMIC AND HYPERKALEMIC
PERIODIC PARALYSIS; 5 GENES
 (NGS333) MALIGNANT HYPERTHERMIA; 2 GENES
 (NGS330**) MD/ MYOPATHY, COMPREHENSIVE; 185
GENES
 (NGS331) MYASTHENIC SYNDROMES, CONGENITAL; 13
GENES
 (NGS413) CENTRONUCLEAR MYOPATHY; 8 GENES
NEUROPATHY & PAIN SYNDROME PANELS
 (NGS345**) CHARCOT MARIE TOOTH DISEASE; 54
GENES
 (NGS345A**) CHARCOT MARIE TOOTH DISEASE;
AXONAL; 54 GENES
 (NGS345D**) CHARCOT MARIE TOOTH DISEASE;
DEMYELINATING 54 GENES
 (NGS346) HEREDITARY SENSORY & AUTONOMIC
NEUROPATHY, AUTOSOMAL RECESSIVE AND PAIN
SYNDROMES; 21 GENES
 (NGS400) PAIN SYNDROMES; 30 GENES
OPHTHALMOPLEGIA SYNDROME PANELS
 (NGS352**) COMPREHENSIVE OPHTHALMOPLEGIA; 55
GENES
 (NGS353**) CELLULAR ENERGETICS
OPHTHALMOPLEGIA; 22 GENES
 (NGS354) NON-MITOCHONDRIAL OPHTHALMOPLEGIA;
32 GENES
NEURONAL MIGRATION & BRAIN MALFORMATION
DISORDERS
 (NGS387**) COMPREHENSIVE NEURONAL MIGRATION;
109 GENES
 (NGS388) NON-MITOCHONDRIAL NEURONAL
MIGRATION; 99 GENES
 (NGS389**) MITOCHONDRIAL NEURONAL MIGRATION;
11 GENES
 (NGS394) JOUBERT SYNDROME; 21 GENES
 (NGS395) MECKEL SYNDROME; 11 GENES
SPASTIC PARAPLEGIA DISORDERS
 (NGS337**) SPASTIC PARAPLEGIA, COMPREHENSIVE;
59 GENES
METABOLIC DISORDERS
CELLULAR ENERGETICS PANELS
 (NGS301**) CELLULAR ENERGETICS, COMPREHENSIVE;
431 GENES (INCLUDES CARBOHYDRATE/LIPID/
PDH/TCA/OXPHOS)
 (NGS301L) CELLULAR ENERGETICS, COMPREHENSIVE;
704 GENES (INCLUDES CARBOHYDRATE/LIPID/
PDH/TCA/OXPHOS)
 (NGS306**) OXIDATIVE PHOSPHORYLATION; 232
GENES
 (NGS306L) OXIDATIVE PHOSPHORYLATION; 429 GENES
 (NGS351**) LEIGH DISEASE AND LEIGH-LIKE
SYNDROMES; 75 GENES
 (NGS198) MTDNA DEPLETION/ MTDNA DELETION
SYNDROMES; 17 GENES
 (NGS197) COENZYME Q10 DEFICIENCY; 12 GENES
 (NGS355**) CYTOCHROME C OXIDASE DEFICIENCY; 44
GENES
 (NGS305**) PYRUVATE AND TRICARBOXYLIC ACID
METABOLISM; 28 GENES
 (NGS304**) PYRUVATE METABOLISM; 14 GENES
 (NGS302**) CARBOHYDRATE METABOLISM; 64 GENES
 (NGS308) CREATINE METABOLISM; 5 GENES
 (NGS311) GLUTARIC ACIDEMIA; 8 GENES
 (NGS312) KETONE BODY METABOLISM; 5 GENES
 (NGS303**) LIPID METABOLISM; 71 GENES
 (NGS303L) LIPID METABOLISM; 122 GENES
HEPATOMEGALY AND METABOLIC DISEASE
 (NGS383**) METABOLIC DISEASE HEPATOMEGALY; 79
GENES
 (NGS384) CARBOHYDRATE METABOLISM,
HEPATOMEGALY; 11 GENES
HYPOTHYROIDISM PANEL
 (NGS404) HYPOTHYROIDISM; 7 GENES
METABOLIC PATHWAY SPECIFIC PANELS
 (NGS309) COBALAMIN/ HOMOCYSTEINE/ METHIONINE
METABOLISM; 20 GENES
 (NGS327) CONGENITAL GLYCOSYLATION DISORDERS; 45
GENES
 (NGS393) MAPLE SYRUP URINE DISEASE; 4 GENES
 (NGS314) METHYLMALONIC ACID METABOLISM; 13
GENES
 (NGS396) PORPHYRIA DISORDERS; 11 GENES
 (NGS321) UREA CYCLE; 16 GENES
PEROXISOME AND LYSOSOME DISEASE PANELS
 (NGS307) CEROID LIPOFUSCINOSIS; 13 GENES
 (NGS313) LYSOSOMAL DISEASE; 72 GENES
 (NGS381) MUCOPOLYSACCHARIDOSIS; 13 GENES
 (NGS343) PEROXISOMAL DISEASE; 32 GENES
CARDIAC DISEASE
ARRHYTHMIA PANELS
 (NGS365) ARRHYTHMIA; COMPREHENSIVE; 57 GENES
 (NGS369) BRUGADA SYNDROME; 16 GENES
 (NGS366) VENTRICULAR TACHYCARDIA; 30 GENES
 (NGS367) ARRHYTHMOGENIC RIGHT VENTRICULAR
DYSPLASIA; 10 GENES
 (NGS368) LONG AND SHORT QT SYNDROMES; 17 GENES
CARDIOMYOPATHY PANELS
 (NGS363**) CARDIOMYOPATHY, COMPREHENSIVE; 131
GENES
 (NGS364) LEFT VENTRICULAR NONCOMPACTION; 8
GENES
CONGENITAL HEART DEFECTS PANELS
 (NGS370) CONGENITAL HEART DEFECTS; 77 GENES
 (NGS399) HETEROTAXY SYNDROMES; 7 GENES
HEARING & VISION SYNDROMES
 (NGS401) STICKLER SYNDROME; 5 GENES
 (NGS402) USHER SYNDROME; 12 GENES
CONNECTIVE TISSUE DISEASE & BONE DISORDERS
 (NGS377) EHLERS DANLOS, EHLERS DANLOS-LIKE
SYNDROMES, AND ANEURYSM SYNDROME; 46 GENES
 (NGS378) MARFAN AND MARFAN-LIKE SYNDROMES; 17
GENES
 (NGS414) NOONAN SYNDROME; 8 GENES
 (NGS397) OSTEOGENESIS IMPERFECTA; 13 GENES
FEVER SYNDROMES
 (NGS319) FEVER SYNDROMES; 36 GENES
AMYLOID RELATED DISORDERS
 (NGS380) AMYLOID RELATED DISORDERS; 18 GENES
KIDNEY DISEASE
 (NGS379) POLYCYSTIC KIDNEY DISEASE; 5 GENES
 (NGS392) BARTTER/GITELMAN SYNDROMES; 7 GENES
** INDICATES TEST CODE WHICH INCLUDES MTDNA SEQUENCING
PAGE 1 OF 2
201608NGS
NEXT-GENERATION
DNA SEQUENCING
TEST REQUEST FORM
5424 Glenridge Drive NE
Atlanta, GA 30342 USA
toll-free: 844.TESTMNG
fax: 678.225.0212
mnglabs.com
No Sunday or Holiday Deliveries Accepted | CLIA License #11D0703390; State of Georgia License #060-381
PATIENT NAME:
DOB:
VISIT WWW.MNGLABS.COM/SUPPORT TO SUBMIT QUESTIONS BY SECURE HIPAA-COMPLIANT EMAIL FOR RAPID RESPONSE TO QUESTIONS.
VISIT WWW.MNGLABS.COM/TESTS FOR DESCRIPTIONS OF EACH GENE AND EACH TEST, AS WELL MOLECULAR DIFFERENTIAL DIAGNOSIS SEARCH.
ORDER TEST KITS ONLINE AT WWW.MNGLABS.COM/KITS FOR SIMPLE SAMPLE PROCESSING, AND FREE INBOUND AND RETURN OVERNIGHT SHIPPING.
PATIENT AND SPECIMEN INFORMATION
PATIENT LAST NAME
PATIENT FIRST NAME
PATIENT ID #
DATE OF BIRTH [MM/DD/YYYY]
DIAGNOSIS/ICD-10
COLLECTION DATE [MM/DD/YYYY]
 MALE
GENDER
 FEMALE
 WHOLE BLOOD
 FIBROBLASTS
 SKIN [FOR CULTURE]  PLASMA
 BUCCAL SWAB
 MUSCLE
 DNA [DNA ISOLATION TISSUE]
SPECIMEN TYPE
 URINE
 CSF
REFERRING PHYSICIAN INFORMATION
REFERRING PHYSICIAN NAME
SIGNATURE
REFERRING PHYSICIAN NPI # (REQUIRED)
FACILITY/ORGANIZATION
PHONE
SELECT AND PROVIDE EMAIL OR FAX FOR
 EMAIL
REPORT DELIVERY
 FAX
BILLING INFORMATION
FACILITY RESPONSIBLE FOR PAYMENT
PHONE
FACILITY CONTACT PERSON
EMAIL
FACILITY BILLING ADDRESS 1
FAX
FACILITY BILLING ADDRESS 2
CITY, STATE, ZIP CODE
RESULTS (SENT BY SECURE HIPAA-COMPLIANT EMAIL OR FAX)
AUTHORIZED RESULTS RECIPIENT 1
AUTHORIZED RESULTS RECIPIENT 2
NAME
FACILITY
PHONE
MARK BOX AND FILL IN INFORMATION FOR PREFERRED RESULTS TRANSMISSION METHOD
FAX

EMAIL



CLINICAL INFORMATION: PLEASE INCLUDE/ ATTACH CLINICAL INFORMATION
CLINICAL INFORMATION FORM AVAILABLE AT MNGLABS.COM/FORMS
PAGE 2 OF 2
201608NGS
CLINICAL INFORMATION FORM
5424 Glenridge Drive NE
Atlanta, GA 30342 USA
toll-free: 844.TESTMNG
fax: 678.225.0212
mnglabs.com
No Sunday or Holiday Deliveries Accepted | CLIA License #11D0703390; State of Georgia License #060-381
Patient Name (Last, First):
Date of Birth (MM/DD/YYYY):
Gender:
NEUROLOGY
EYE
CLINICAL (CIRCLE ALL THAT APPLY)
COMMENTS
NERVE/ANTERIOR HORN CELL
CHARCOT-MARIE-TOOTH
NERVE CONDUCTION
SENSORY
MOTOR
AUTONOMIC
PAIN
NEUROFIBROMAS
OTHER
CARDIOLOGY
COMMENTS
CARDIOMYOPATHY
DILATED
HYPERTROPHIC
NONCOMPACTION
ARRHYTHMIAS
VENTRICULAR TACHYCARDIA
LONG OR SHORT QT
CONDUCTION DEFECT
BRUGADA
CONGENITAL HEART DEFECTS
DESCRIBE
HETEROTAXY
ENDOCRINE
COMMENTS
DIABETES MELLITUS
HYPOTHYROIDISM
OTHER
CONNECTIVE TISSUE/BONE
COMMENTS
EHLERS DANLOS
MARFAN
ANEURYSMS
OSTEOGENESIS IMPERFECTA
OTHER
ADDITIONAL COMMENTS
OPTIC ATROPHY
RETINITIS PIGMENTOSA
OTHER
HEARING
 Male  Female
SENSORINEURAL
STICKLER
USHER
COGNITIVE/NEUROBEHAVIORAL
INTELLECTUAL DISABILITY (ID)
SYNDROMIC ID
NONSYNDROMIC ID
AUTISM
DEMENTIA
EPILEPSY
TONIC CLONIC
ABSENCE
MYOCLONIC
EPILEPTIC ENCEPHALOPATHY
OTHER
NEURONAL MIGRATION
JOUBERT
MECKEL
OTHER
STROKE
MOVEMENT DISORDER
ATAXIA
EPISODIC ATAXIA
DYSTONIA
CHOREA/ATHETOSIS
PARKINSON DISEASE
L-DOPA RESPONSE
SPASTICITY
SPASTIC QUADRIPLEGIA
SPASTIC PARAPLEGIA
OTHER
NEUROMUSCULAR
PROXIMAL OR DISTAL
MUSCLE ATROPHY
RHABDOMYOLYSIS
STATIN USE
MALIGNANT HYPERTHERMIA
CONTRACTURES
ARTHROGRYPOSIS
MYASTHENIA
PERIODIC PARALYSIS
Confidential
Page 1 of 2
201601CLINICALINFO
CLINICAL INFORMATION FORM
5424 Glenridge Drive NE
Atlanta, GA 30342 USA
toll-free: 844.TESTMNG
fax: 678.225.0212
mnglabs.com
No Sunday or Holiday Deliveries Accepted | CLIA License #11D0703390; State of Georgia License #060-381
Patient Name (Last, First):
Date of Birth (MM/DD/YYYY):
Gender:
IMAGING (CIRCLE ALL THAT APPLY)
BRAIN MRI
LEIGH DISEASE
BASAL GANGLIA CALCIFICATION
STROKE
CEREBELLAR ATROPHY
ABNORMAL MYELIN
(DESCRIBE)
EEG (DESCRIBE FINDINGS)
 Male  Female
AFFECTED MATERNAL LINEAGE
RELATIONSHIP TO PROBAND
SYMPTOMS
AFFECTED PATERNAL LINEAGE
RELATIONSHIP TO PROBAND
SYMPTOMS
EMG/NCV (DESCRIBE FINDINGS)
LABORATORY
METABOLIC (DESCRIBE FINDINGS)
SIBLINGS
NUMBER (SPECIFY GENDER)
HEALTHY/AFFECTED
CPK
MAXIMUM
MINIMUM
ETHNICITY (PLEASE CIRCLE)
GENETIC (DESCRIBE FINDINGS)
CHROMOSOME MICROARRAY







DELETION/INSERTION TESTING
OTHER
AFRICAN
EAST ASIAN
SOUTH ASIAN
EUROPEAN (NON- FINNISH)
EUROPEAN (FINNISH)
LATINO
OTHER: ________________________
FAMILY HISTORY
Confidential
Page 2 of 2
201601CLINICALINFO