Prenatal Testing Requisition Form
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BAYLOR MIRACA GENETICS LABORATORIES SHIP TO: Baylor Miraca Genetics Laboratories 2450 Holcombe, Grand Blvd. -Receiving Dock PHONE: 800-411-GENE | FAX: 713-798-2787 | www.bmgl.com Houston, TX 77021-2024 Phone: 713-798-6555 PRENATAL COMPREHENSIVE REQUISITION FORM PATIENT INFORMATION NAME (LAST,FIRST, MI): DATE OF BIRTH (MM/DD/YY): HOSPITAL#: ACCESSION#: REPORTING INFORMATION ADDITIONAL PROFESSIONAL REPORT RECIPIENTS PHYSICIAN: NAME: INSTITUTION: PHONE: FAX: PHONE: FAX: NAME: EMAIL (INTERNATIONAL CLIENT REQUIREMENT): PHONE: FAX: SAMPLE INFORMATION CLINICAL INDICATION FETAL SPECIMEN TYPE Pregnancy at risk for specific genetic disorder DATE OF COLLECTION: (Complete FAMILIAL MUTATION information below) Amniotic Fluid: cc AMA PERFORMING PHYSICIAN: CVS: mg TA TC Abnormal Maternal Screen: Fetal Blood: cc GESTATIONAL AGE (GA) Calculation for AF-AFP* NTD TRI 21 TRI 18 Other: SELECT ONLY ONE: Abnormal NIPT (attach report): POC/Fetal Tissue, Type: TRI 21 TRI 13 TRI 18 Other: Cultured Amniocytes U/S DATE (MM/DD/YY): Abnormal U/S (SPECIFY): Cultured CVS GA ON U/S DATE: WKS DAYS PARENTAL BLOODS - REQUIRED FOR CMA -OR- Maternal Blood Date of Collection: Multiple Pregnancy Losses LMP DATE (MM/DD/YY): Parental Concern Paternal Blood Date of Collection: Other Indication (DETAIL AND ATTACH REPORT): *Important: U/S dating will be used if no selection is made. Name: Note: Results will differ depending on method checked. Last Name First Name U/S dating increases overall screening performance. Date of Birth: KNOWN FAMILIAL MUTATION/DISORDER SPECIFIC PRENATAL TESTING Notice: Prior to ordering testing for any of the disorders listed, you must call the lab and discuss the clinical history and sample requirements with a genetic counselor. Please call 713-798-6555. Specimen Requirements/Orders discussed with (NAME OF BMGL GENETIC COUNSELOR): Date: Additional Cultures to be sent later: YES NO Cultures will be sent from (NAME OF LABORATORY): GENE NAME: FAMILIAL MUTATION REPORT MUST BE ATTACHED BMGL FAMILY #: PLEASE MARK CORRESPONDING GENE RELATED DISORDER ON PAGES 3-11 WAS CARRIER TESTING PERFORMED THROUGH GeneAware? YES NO NOTICE FOR PRENATAL BIOCHEMICAL AND DNA TESTS: Please be aware that our specimen requirements and quality control measures are compliant with the American College of Medical Genetics (ACMG) Standards and Guidelines for Clinical Genetics Laboratories. While these requirements are intended to provide the highest level of assurance that a single laboratory can offer, the ideal practice to assure the accuracy of prenatal diagnosis testing is through duplicate testing conducted by independent laboratories. We recommend that referring medical professionals make the necessary arrangements for these two independent analyses for their patients prior to performing the prenatal diagnostic procedure. PHYSICIAN/COUNSELOR ACKNOWLEDGEMENT:________________________________________________________________________________________________________________ OTHER PRENATAL TESTING OPTIONS For Disorder Specific Testing, please see following pages. IMPORTANT INSTRUCTIONS FOR CMA: Parental Bloods (Draw 5-7 cc in an EDTA tube) are required for CMA. Label with NAME and DOB and complete Parental Bloods Information above. CMA OPTIONS (Select one): CHROMOSOME ANALYSIS TARGETED CMA (180K oligo copy number and targeted chrom SNP array) ANEUPLOIDY FISH (24-48hrs for 13,18,21, X and Y) TARGETED CMA + LIMITED CHROMOSOME ANALYSIS (5 cell karyotype) AF-AFP EXPANDED CMA (400K oligo copy number and all chrom SNP array) AChE EXPANDED CMA + LIMITED CHROMOSOME ANALYSIS (5 cell karyotype) COL1A1 & COL1A2 -RELATED DISORDERS PANEL (see page 2) *Cultured Fetal Samples are not accepted for CMA Comprehensive Options. NOONAN SPECTRUM DISORDERS PANEL (see page 2) REQUIRED: NEW YORK STATE PHYSICIAN SIGNATURE OF CONSENT I certify that the patient specified above and/or their legal guardian has been informed of the benefits, risks, and limitations of the laboratory test(s) requested. I have answered this person's questions. I have obtained informed consent from the patient or their legal guardian for this testing. Physician's Printed Name: _________________________________ Signature: ______________________________________ Date (MM/DD/YY): _____________ Page 1 of 13 LAST UPDATED: 2/5/2015 BAYLOR MIRACA GENETICS LABORATORIES SHIP TO: Baylor Miraca Genetics Laboratories 2450 Holcombe, Grand Blvd. -Receiving Dock PHONE: 800-411-GENE | FAX: 713-798-2787 | www.bmgl.com Houston, TX 77021-2024 Phone: 713-798-6555 PRENATAL COMPREHENSIVE REQUISITION FORM NAME: DATE OF BIRTH: / / LAST NAME FIRST NAME MI MM DD YY NOONAN SPECTRUM DISORDERS TESTING This prenatal panel is intended for fetal samples with ultrasound findings suggestive of Noonan Spectrum Disorders. Please see the website for fetal specimen information. Specimen Requirements/Orders discussed with (NAME OF BMGL GENETIC COUNSELOR): Date: Cultures to be sent later: YES NO Cultures will be sent from (NAME OF LABORATORY): BIOLOGICAL PARENTS SAMPLES are required for fetal testing. Send 5-7 cc in EDTA. Be sure to label parental samples with full name and date of birth. If parental blood is also submitted for CMA no additional blood is needed 21401: MOTHER (FULL NAME): DOB: / / LAST NAME FIRST NAME MM DD YY Does this parent have features of Noonan Syndrome? ASYMPTOMATIC SYMPTOMATIC - attach summary of findings or describe here: DATE OF COLLECTION (MM/DD/YY): NOT AVAILABLE TO BE SENT LATER* 21401: FATHER (FULL NAME): DOB: / / LAST NAME FIRST NAME MM DD YY Does this parent have features of Noonan Syndrome? ASYMPTOMATIC SYMPTOMATIC - attach summary of findings or describe here: DATE OF COLLECTION (MM/DD/YY): NOT AVAILABLE TO BE SENT LATER* *If parent samples are to be sent later, please include copy of this requisition form with those samples. COL1A1 & COL1A2 -RELATED DISORDERS TESTING This prenatal panel is intended for fetal samples with ultrasound findings suggestive of COL1A1 & COL1A2 - Related Disorders. Please see the website for fetal specimen information. Specimen Requirements/Orders discussed with (NAME OF BMGL GENETIC COUNSELOR): Date: Cultures to be sent later: YES NO Cultures will be sent from (NAME OF LABORATORY): BIOLOGICAL PARENTS SAMPLES are required for fetal testing. Send 5-7 cc in EDTA. Be sure to label parental samples with full name and date of birth. If parental blood is also submitted for CMA no additional blood is needed 2626: MOTHER (FULL NAME): DOB: / / LAST NAME FIRST NAME MM DD YY Does this parent have features of COL1A1 or COL1A2 condition? ASYMPTOMATIC SYMPTOMATIC - attach summary of findings or describe here: DATE OF COLLECTION (MM/DD/YY): NOT AVAILABLE TO BE SENT LATER* 2626: FATHER (FULL NAME): DOB: / / LAST NAME FIRST NAME MM DD YY Does this parent have features of COL1A1 or COL1A2 condition? ASYMPTOMATIC SYMPTOMATIC - attach summary of findings or describe here: DATE OF COLLECTION (MM/DD/YY): NOT AVAILABLE TO BE SENT LATER* *If parent samples are to be sent later, please include copy of this requisition form with those samples. Page 2 of 13 LAST UPDATED: 2/5/2015 BAYLOR MIRACA GENETICS LABORATORIES SHIP TO: Baylor Miraca Genetics Laboratories 2450 Holcombe, Grand Blvd. -Receiving Dock PHONE: 800-411-GENE | FAX: 713-798-2787 | www.bmgl.com Houston, TX 77021-2024 Phone: 713-798-6555 PRENATAL COMPREHENSIVE REQUISITION FORM NAME: DATE OF BIRTH: / / LAST NAME FIRST NAME MI MM DD YY DISORDER SPECIFIC TESTING Notice: Prior to ordering any of the disorders listed below, you must call the lab and discuss the clinical history and sample requirements with a genetic counselor. 2,4-Dienoyl-CoA Reductase Deficiency DECR1 ATP5A1-Related Disorders 2-Methyl-3-Hydroxybutyryl-CoA Dehydrogenase Deficiency HSD17B10 ATP6V0A2-Related Disorders 3-Hydroxy-3-Methylglutaryl CoA lyase Deficiency HMGCL Autoimmune Polyendocrinopathy 1 (APECED) AIRE 3-Hydroxy-3-Methylglutaryl-CoA Synthase 2 Deficiency HMGCS2 Autosomal Recessive Congenital Ichthyosis, TGM1-Related 3-Methylcrotonyl-CoA Carboxylase Deficiency, MCCC1-Related Autosomal Recessive Polycystic Kidney Disease PKHD1 3-Methylcrotonyl-CoA Carboxylase Deficiency, MCCC2-Related B4GALT7-Related Disorders 3-Methylglutaconic Aciduria Type 1, AUH-Related BAG3-Related Disorders ABCA4-Related Disorders Bardet-Biedl Syndrome 1, BBS1 ABCC8-Related Disorders (Diabetes Mellitus, Permanent Neonatal) Bardet-Biedl Syndrome 2, BBS2 ACACA-Related Disorders Bardet-Biedl Syndrome 4, BBS4 ACACB-Related Disorders ACTA1-Related Disorders Bardet-Biedl Syndrome 5, BBS5 Acute Myeloid Leukemia CEBPA Bardet-Biedl Syndrome 7, BBS7 Acute Recurrent Myoglobinuria, LPIN1-Related Bardet-Biedl Syndrome 9, BBS9 Acyl-CoA Dehydrogenase, Short/Branched Chain Deficiency ACADSB Bardet-Biedl Syndrome 10, BBS10 Adenine Phosphoribosyltransferase Deficiency APRT Bardet-Biedl Syndrome 12, BBS12 Adenosine Deaminase Deficiency Bardet-Biedl Syndrome 15, WDPCP Adenylosuccinase Deficiency ADSL Adrenoleukodystrophy ABCD1 Bardet-Biedl Syndrome 17, LZTFL1 AKT2-Related Disorders Bardet-Biedl Syndrome, Modifier of, CCDC28B Alagille Syndrome JAG1 Bare Lymphocyte Syndrome Type I TAP1 Alpha-Mannosidosis MAN2B1 Bare Lymphocyte Syndrome Type II RFX5 ALPL-Related Disorders (Hypophosphatasia) Bare Lymphocyte Syndrome Type II, CGA, CIITA AMACR-Related Disorders Bare Lymphocyte Syndrome Type II, CGD, RFXAP Amish Lethal Microcephaly SLC25A19 (THMD3) Barth Syndrome TAZ Androgen Insensitivity Syndrome AR Beta-Thalassaemia/Sickle Cell Anemia HBB Angelman Syndrome UBE3A BH4-Deficient Hyperphenylalaninemia A PTS Angelman-Like Syndrome, X-Linked SLC9A6 (NHE6)