GENETIC TESTING REQUISITION

1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Attention Patient: Please visit your nearest LifeLabs or CML Healthcare Patient Service Centre for sample collection

CONTRACT # LL: K012-01/ CML: CEN

Report to Physician Billing # LifeLabs Demographic Label Ordering Physician Name

Physician Signature:

Ordering Physician Address: Tel: Fax: Address & Contact Info:

Copy to (name & contact info): Name: Contact:

Bill to Contract # K012-01 (patient does not pay at time of collection) Patient Gender: (M/F)

Patient Name (Last, First): Patient DOB: (YYYY/MM/DD)

Patient Address: Patient Health Card: Patient Telephone:

Please ship all NON-PRENATAL samples to: LifeLabs · Attn CDS Department • 100 International Boulevard• Toronto ON• M9W6J6 TEST REQUESTED LL TR # / CML TC# □ Genetic Test - Blood Sample 2 x 4mL EDTA 4005 □ Genetic Test (Pediatric) - Blood Sample 1 x 2mL EDTA 4008 □ Genetic Test - Other Sample Type 4014 PRENATAL SAMPLES: Please ship directly to CENTOGENE.

Date Blood Collected (YYYY/MM/DD): ______Time Blood Collected (HH:MM)) :______Collector Name: ______

GENETIC TESTING CONSENT I understand that a DNA specimen will be sent to LifeLabs for genetic testing. My physician has told me about the condition(s) being tested and its genetic basis. I am aware that correct information about the relationships between my family members is important. I agree that my specimen and personal health information may be sent to Centogene AG at their lab in Germany (address below). To ensure accurate testing, I agree that the results of any genetic testing that I have had previously completed by Centogene AG may be shared with LifeLabs. I understand that LifeLabs will contact me for a new specimen if a test result cannot be provided from the original specimen. I agree that a copy of my results will be sent to my ordering physician. I further agree that for any test(s) performed by Centogene AG, a copy of my results will also be sent to LifeLabs. I understand that once the requested test(s) has/have been completed, any remaining sample will be stored at the testing laboratory.

OPTIONAL CONSENT : Please Initial where appropriate

_____ I agree that my de-identified sample may be used for product development or research purposes. I understand that I will not receive any royalties, resultant payments, benefits or rights to products or discoveries. _____ I do not want my remaining sample to be stored. Please destroy any remaining sample once the final report has been issued. _____ I have had genetic testing completed in the past by the following laboratories: ______I agree that Centogene AG and LifeLabs may obtain a copy of these genetic test results from the testing laboratory.

Patient/Substitute Decision Maker: Signature: ______; Date: ______

Printed name: ______; Relationship to person being tested: ______

OR: I certify that verbal consent was obtained from the patient /substitute decision maker for the requested genetic testing

Signature: ______; Date: ______

** LIFELABS/CML STAFF: PHOTOCOPY REQUISITION AND INCLUDE 1 COPY WITH SAMPLES**

Page 1/4 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V2 Oct2014

GENETIC TESTING REQUISITION EAR, NOSE & THROAT 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD):

Sample Type: □ *Blood (EDTA: 5mL for single gene, 10mL for panel)

□ DNA (single gene:1-10ug, panel 10-100ug)

□ *Filter card (1 card/30 exons: Available by request) LifeLabs Demographic □ Saliva (Oragene OG-510: Available by request) Label

□ Fibroblast/Skin Biopsy (0.5cm2)

□ Cultured cells (1 flask, min 25cm2, 80-90% confluent)

□ **Amniotic fluid (10mL)

□ **Chorionic Villus (10 villi, cleaned) □ Other: ______

* Exact amount depends on size of panel, see www.centogene.com ** Please contact us prior to sending cells

Billing Status: □ Ministry of Health Approved (Approval letter attached) □ Ministry of Health Approval Pending

□ Institution (Complete information below) □ Private Pay (Complete information below)

Institution Billing ONLY: Institution Name: ______Contact Name: ______

Address:

Phone: ( ) - Fax: ( ) - Email: ______Private Pay ONLY: Credit Card Type: □ MasterCard □ Visa

Card Number______Exp Date(MM/YY)______

Name (as it appears on credit card)______I understand that my credit card will be charged for the full amount of testing not paid for by my provincial health plan

Cardholder Signature: ______Date (DD/MM/YYYY)______

Patient Information: Gender: □M □ F Ethnicity: ______Additional patient medical information:

Relevant Family history:

Have other family members submitted samples to Centogene for analysis? □Y □ N If yes, Name:______Relationship to patient ______

DOB (YYYY/MM/DD):______

Familial Mutation Testing Gene:______Mutation (HGVS):______□Familial Report attached

Testing Instructions: (ex: Reflex order) ** PLEASE INCLUDE A COPY OF REQUISITION WITH SAMPLES ** (Testing performed at Centogene AG, Schillingallee 68, 18057 Rostock Germany) Page 2/4 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V2 Oct2014

GENETIC TESTING REQUISITION EAR, NOSE & THROAT 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD):

Please indicate requests for Hot Spot (H), Exon (E), Sequencing (S), and/or Deletion/Duplication (D) analysis

Non-syndromic Hearing Loss

NGS Panels: Deafness, non-syndromic sensorineural (CDH23, CLDN14, COL11A2, DFNB31, DFNB59, ESPN, ESRRB, GIPC3, GJB2, GJB3, GJB6, GPSM2, GRXCR1, HGF, ILDR1, KCNJ10, D S LHFPL5, LOXHD1, LRTOMT, MARVELD2, MSRB3, MYO15A, MYO3A, MYO6, MYO7A, OTOA, OTOF, PCDH15, POU3F4, PRPS1 PTPRQ, autosomal recessive panel RDX, SERPINB6, SLC12A1, SLC26A4, SLC26A5, SMPX, STRC, TECTA, TMC1, TMIE, TMPRSS3, TPRN, TRIOBP, USH1C) Deafness, non-syndromic sensorineural (ACTG1, CCDC50, COCH, COL11A2, CRYM, DFNA5, DIABLO, DIAPH1, DIAPH3, DSPP, EYA4, GJB2, GJB3, GJB6, GRHL2, KCNQ4, D S autosomal dominant panel MIR96, MYH14, MYH9, MYO1A, MYO6, MYO7A, POU3F4, POU4F3, PRPS1, SIX1, SLC17A8, SMPX, TECTA, TJP2, TMC1, WFS1) Single genes: D S Deafness, autosomal recessive (SYNE4) D S Deafness, autosomal recessive type 79 (TPRN)

D S Deafness, autosomal recessive (SUN1) D S Deafness, autosomal recessive type 84 (PTPRQ)

D S Deafness, autosomal recessive (GJB3) D S Deafness, autosomal recessive type 91 (SERPINB6)

H D S Deafness, autosomal recessive type 1A (GJB2) D S Deafness, autosomal dominant type 1 (DIAPH1) H D S Deafness, autosomal recessive type 1B (GJB6) D S Deafness, autosomal dominant type 2A (KCNQ4) H D S Deafness, autosomal recessive type 2 (MYO7A) D S Deafness, autosomal dominant type 2B (GJB3) H D S Deafness, autosomal recessive type 3 (MYO15A) H D S Deafness, autosomal dominant type 3A (GJB2) D S Deafness, autosomal dominant type 4 (MYH14) H D S Deafness, autosomal dominant type 3B (GJB6) D S Deafness, autosomal recessive type 6 (TMIE) D S Deafness, autosomal dominant type 4 (MYH14) H D S Deafness, autosomal recessive type 7 (TMC1) D S Deafness, autosomal dominant type 5 (DFNA5) D S Deafness, autosomal recessive type 8/10 (TMPRSS3) D S Deafness, autosomal dominant type 6 (WFS1) H D S Deafness, autosomal recessive type 9 (OTOF) D S Deafness, autosomal dominant type 9 (COCH) D S Deafness, autosomal recessive type 15 (GIPC3) D S Deafness, autosomal dominant type 10 (EYA4) H D S Deafness, autosomal recessive type 16 (STRC) H D S Deafness, autosomal dominant type 11 (MYO7A) H D S Deafness, autosomal recessive type 18 (USH1C) D S Deafness, autosomal dominant type 12 (TECTA) D S Deafness, autosomal recessive type 22 (OTOA) H D S Deafness, autosomal dominant type 13 (COL11A2) D S Deafness, autosomal recessive type 23 (PCDH15) D S Deafness, autosomal dominant type 15 (POU4F3) D S Deafness, autosomal recessive type 24 (RDX) D S Deafness, autosomal dominant type 17 (MYH9) D S Deafness, autosomal recessive type 25 (GRXCR1) D S Deafness, autosomal dominant type 20 (ACTG1) D S Deafness, autosomal recessive type 28 (TRIOBP) D S Deafness, autosomal dominant type 22 (MYO6) D S Deafness, autosomal recessive type 29 (CLDN14) D S Deafness, autosomal dominant type 23 (SIX1) D S Deafness, autosomal recessive type 30 (MYO3A) D S Deafness, autosomal dominant type 25 (SLC17A8) D S Deafness, autosomal recessive type 31 (DFNB31) D S Deafness, autosomal dominant type 28 (GRHL2) D S Deafness, autosomal recessive type 35 (ESRRB) H D S Deafness, autosomal dominant type 36 (TMC1) D S Deafness, autosomal recessive type 36 (ESPN) D S Deafness, autosomal dominant type 39 (DSPP) H D S Deafness, autosomal recessive type 39 (HGF) D S Deafness, autosomal dominant type 40 (CRYM) D S Deafness, autosomal recessive type 42 (ILDR1) D S Deafness, autosomal dominant type 44 (CCDC50) H D S Deafness, autosomal recessive type 48 (CIB2) D S Deafness, autosomal dominant type 48 (MYO1A) D S Deafness, autosomal recessive type 49 (MARVELD2) E D S Deafness, autosomal dominant type 50 (MIR96) H D S Deafness, autosomal recessive type 53 (COL11A2) D S Deafness, autosomal dominant type 52 (POU4F3) D S Deafness, autosomal recessive type 59 (DFNB59) D S Deafness, autosomal dominant type 64 (DIABLO) D S Deafness, autosomal recessive type 61 (SLC26A5) H D S Deafness, X-linked type 1 (PRPS1) D S Deafness, autosomal recessive type 63 (LRTOMT) D S Deafness, X-linked type 2 (POU3F4) D S Deafness, autosomal recessive type 67 (LHFPL5) D S Deafness, X-linked type 4 (SMPX) D S Deafness, autosomal recessive type 74 (MSRB3) D S Deafenss nonsyndromic sensorineural mitochondrial (MT-RNR1) D S Deafness, autosomal recessive type 77 (LOXHD1) D S Mitochondrial modifier of deafness (TRMU)

Other

NGS Panels:

D S Alport syndrome panel (COL4A3, COL4A4, COL4A5) (AHI1, ARL13B, B9D1, B9D2, C5orf42, CC2D2A, CEP290, CEP41, CSPP1, EXOC8, INPP5E, KIF7, MSK1, NPHP1, NPHP3, OFD1, RPGRIP1L, TCTN1, D S Joubert syndrome panel TCTN2, TMEM138, TMEM216, TMEM231, TMEM237, TMEM67, TTC21B, ZNF423) (DNAI1, DNAAF3, DNAH5, HYDIN , NME8, DNAH11, DNAI2 , RSPH4A, RSPH9, DNAAF1, CCDC39 , CCDC40, DNAL1, CCDC103, HEATR2, LRRC6, D S Primary cilary dyskinesia panel CCDC114) Single genes:

D S Alport syndrome, autosomal recessive (COL4A3) D S Bjornstad syndrome (BCS1L) D S Alport syndrome, autosomal recessive (COL4A4) D S Branchiootorenal syndrome type 1 (EYA1) D S Alport syndrome, X-Linked (COL4A5) D S Branchiootorenal syndrome type 2 (SIX5) D S Auditory neuropathy, autosomal dominant (DIAPH3) D S Brown-Vialetto-Van Laere syndrome 1 (SLC52A3) D S Auriculocondylar syndrome type 1 (GNA13) D S CHARGE syndrome (CHD7) D S Auriculocondylar syndrome type 2 (PLCB4) D S Chudley-McCullough syndrome (GPSM2)

Page 3/4 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V2 Oct2014

GENETIC TESTING REQUISITION EAR, NOSE & THROAT 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD):

Other (Continued)

D S Ciliogenesis related disorder (PTPN23) D S Otofaciocervical syndrome (EYA1) D S Dystonia-deafness syndrome (TIMM8A) D S Otopaladigital syndrome type 1 (FLNA) D S Epstein syndrome (MYH9) D S Otopaladigital syndrome type 2 (FLNA) D S Fazio-Londe disease (SLC52A3) S Pendred syndrome (SLC26A4) D S Growth retardation with deafness and mental retardation due to IGF1 deficiency (IGF1) D S Primary ciliary dyskinesia type 1 (DNAI1) D S Joubert syndrome type 1 (INPP5E) H D S Primary ciliary dyskinesia type 2 (DNAAF3) D S Joubert syndrome type 2 (TMEM216) H D S Primary ciliary dyskinesia type 3 (DNAH5) D S Joubert syndrome type 3 (AHI1) D S Primary ciliary dyskinesia type 5 (HYDIN) D S Joubert syndrome type 4 (NPHP1) D S Primary ciliary dyskinesia type 6 (NME8) D S Joubert syndrome type 5 (CEP290) D S Primary ciliary dyskinesia type 7 (DNAH11) D S Joubert syndrome type 6 (TMEM67) D S Primary ciliary dyskinesia type 9 (DNAI2) D S Joubert syndrome type 7 (RPGRIP1L) D S Primary ciliary dyskinesia type 11 (RSPH4A) D S Joubert syndrome type 8 (ARL13B) D S Primary ciliary dyskinesia type 12 (RSPH9) D S Joubert syndrome type 9 (CC2D2A) D S Primary ciliary dyskinesia type 13 (DNAAF1) D S Joubert syndrome type 10 (OFD1) D S Primary ciliary dyskinesia type 14 (CCDC39) D S Joubert syndrome type 13 (TCTN1) D S Primary ciliary dyskinesia type 15 (CCDC40) D S Joubert syndrome type 14 (TMEM237) D S Primary ciliary dyskinesia type 16 (DNAL1) D S Joubert syndrome type 15 (CEP41) D S Primary ciliary dyskinesia type 17 (CCDC103) D S Joubert syndrome type 16 (TMEM138) D S Primary ciliary dyskinesia type 18 (HEATR2) D S Joubert syndrome type 17 (C5orf42) D S Primary ciliary dyskinesia type 19 (LRRC6) D S Joubert syndrome type 18 (TCTN3) D S Primary ciliary dyskinesia type 20 (CCDC114) D S Joubert syndrome type 20 (TMEM231) H D S Progressive hearing loss (P2RX2) D S Joubert syndrome type 21 (CSPP1) H D S Tietz albinism-deafness syndrome (MITF) D S Joubert syndrome, EXOC8 related (EXOC8) D S Townes-Brocks syndrome (SALL1) D S Joubert syndrome, EXOSC8 related (EXOSC8) D S Townes-Brocks syndrome (SALL4) D S Joubert syndrome type 4 (NPHP1) D S Wolfram syndrome type 1 (WFS1) D S Opticoacoustic nerve atrophy with dementia (TIMM8A) D S Wolfram syndrome type 2 (CISD2)

Page 4/4 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V2 Oct2014