Download IMP 70.12 REQUISIÇÃO CANCRO DA MAMA HEREDITÁRIO_ingles

GenoMed use only
Identification (Mandatory):
printed label preferred
label
Verified by:
Name:
Gender: F
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M
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Referring doctor:
Date of birth:
Hospital/Service:
Identification number:
Telephone or E-mail:
Clinical Data and Diagnosis:
Familiar information:
Known familiar mutation? No
Index case (affected)
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Yes
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In which gene? BRCA1
Familiar case (affected)
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BRCA2
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Which mutation? …..................................................................
Familiar case (not affected)
Type of cancer:
Left side
Right side
Bilateral
Breast cancer
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…………..
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Ovarian cancer
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…………..
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Other(s): ………………………………………………………………………………….…
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(Fill in laterality information with the age of diagnosis)
Metachronous tumors? Yes
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No
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Attach whenever possible and can be justified any relevant clinical information, family data including consanguinity, other cases in the family, family tree, etc.
Use the back sheet of this requisition form. Information for the construction of the Pedigree:
Male
Female
Affected
Carrier
Deceased
Consanguinity
Index Case
For predictive testing (conducted in healthy individuals) it is ESSENTIAL that the request is made by the clinical geneticist (1).
REQUESTED TEST(S) (COLLECTION IN EDTA TUBE):
34900
Breast cancer: BRCA1 and BRCA2 genes (Sequencing) – index case
34543
Breast cancer: BRCA1 gene (Sequencing) – index case
34900
Breast cancer: BRCA1 gene (MLPA) – index case
34544
Breast cancer: BRCA1 gene (Sequencing) – familiar case
34900
Breast cancer: BRCA1 gene (MLPA) - familiar case
34547
Breast cancer: BRCA2 gene (Sequencing) – index case
34900
Breast cancer: BRCA2 gene (MLPA) – index case
34548
Breast cancer: BRCA2 gene (Sequencing) – familiar case
34900
Breast cancer: BRCA2 gene (MLPA) – familiar case
34200
DNA extraction
(1) Genetical counselling – Place:
Sample: Blood (EDTA) □ DNA □ Other □ ……...................................
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Date: …...../…...../...............
Collection: Date: ...../...../........... Time: …….:…......
Hereby I ………………………………………………………..………………………...….. [name], born at ……/……/…………. [date of birth], give my consent
that my/my child’s blood/DNA sample will be examined for genetic changes (mutations) in the gene(s) specified above related to the diseases/clinical
features described above. Herewith I declare that I have been informed about the chances and limitations of the requested testing procedure. I was
informed in detail about the consequences resulting from the test results. I agree that the sample may be stored in order to allow repetition of the test(s)
or further related tests in the future. All data about me/my child are subject to medical confidentiality. They can be disclosed to family members or their
doctors only with my permission, but not to third parties. I’m entitled to revoke this consent at any time. I agree that my/my child’s test(s) results/clinical
data may be used in scientific publications in anonymized form in case of approval by the Ethics Committee.
Signature:….............................................................................................................. Place and Date: ……………….……………….., …...../…...../…..…….
Signature of the Referring doctor:
Date: …...... /…......./….............
CONTACT PERSON: Dr. Gabriel M.-Miltenyi ([email protected]) Tel: (+351) 21 799 95 01 Ext. 47307/01
IMP 70.12