PagePage 1 1of of 5 3 LondonLondon Health Sciences Sciences Centre Centre – Molecular– (Molecular Diagnostics Genetics) Reason for Referral: Requisition for DNATesting Ph: 519-685-8122 |Fax: 519-685-8279 London, Ontario |N6A5W9 800 Commissioners Rd E. Victoria Hospital, Room B10-123A MOLECULAR GENETICS LABORATORY Clinical Diagnostics andFamily History: Sample Collection: Lab Use Only: CLINICAL INFORMATION ANDFAMILY HISTORY SAMPLE COLLECTION Ph: 519-685-8122 | Fax: 519-685-8279 London, Ontario |N6A 5W9 800 Commissioners Rd. E. Victoria Hospital, Room B10-123A Molecular Genetics Laboratory REASON FOR REFERRAL LAB USEONLY Requisition for DNA Testing Name of index case inthefamily RefSeq:NM: Gene: Relationship to thispatient: Date drawn: Date of Birth: Notes: Received date: Date drawn Referral to anoutsidelaboratory Mutation: Gene: Relationship to thispatient: Date ofBirth: LHSC MD#/Name ofIndex case inthe family Carriertesting/Known Family Mutation Unaffected Affected Diagnostic Testing: Notes: Received date: (slides preferred) Formalin fixed paraffin embeddedtissue(FFPE) Fresh/Frozen Tissue ug DNA (100ngto 1ug): EDTA bonemarrow (lavender top)(min. 2mlat room temp) Referral to anoutside laboratory RNA Banking DNA Banking FamilyCarrier testing/Known Mutation EDTA blood(lavender top)(min. 2mlat room temp) Prenatal Diagnosis Diagnostic Testing: Other: Other: Formalin fixed paraffin embedded tissue Fresh/Frozen Tissue DNA EDTA bonemarrow EDTA blood Prenatal Diagnosis Unaffected Affected RefSeq:NM: (100ng to 1ug) ( ) YYYY/MM/DD (YYYY/MM/DD) (lavender top)(min. 2mlat room temp)

: ug (provide tissue source): tissue (provide (lavender top)(min. 2mlat room temp) (provide tissuesource) : DNABanking Mutation: (include copy of report): of copy (include

(must specify lab): specify (must (must lab) specify (include copy ofreport) (FFPE -slidespreferred) :

RNABanking

:

:

Referring Physician: INCOMPLETE REQUESTS WILLBEBANKED Patient Information: Request for Expedited Result: Test Requests: AUTHORIZED SIGNATURE ISREQUIRED TEST REQUESTS REFERRING PHYSICIAN REQUEST FOR EXPEDITEDRESULT PATIENT INFORMATION Telephone: Telephone: Address: E-mail address: Address: Name: Signature: Physician name(print): Medical intervention Medical intervention adjacent to theitem of interest. panelssub- orindividualgenes maybeselected usingthecheckbox Use attached menuto select panels orindividualgenes. Panels, CC report to: using thecheckbox adjacent to theitem ofinterest. Panels, sub-panelsorindividualgenes may beselected Use attached menu to selectpanelsorindividual genes. Sex: M Health Card No.: Date ofBirth: Address: Name: Telephone: Address: Name: CC report to: Telephone: Address: Clinic/Hospital: Signature: Physician Name Se Address: Birthdate: Name: Health Card Number: YYYY/MM/DD x: Pregnancy Medical Intervention Pregnancy F aeFemale Male Email: : YY/MM/DD) (L.M.P., (L.M.P., YYYY/MM/DD) (print) Other (specify with date): with (specify : Pathology and LaboratoryMedicine (specify withdate)(specify (INCOMPLETE REQUESTS WILLBEBANKED) Authorized Signature isRequired Fax: Fax: : Fax: Fax: :

NGSMGL(12/04/2017) (08/17/2021) PagePage 1 2of of 5 3 LondonLondon Health Sciences Sciences Centre Centre – Molecular– (Molecular Diagnostics Genetics) Reason for Referral: Requisition for DNATesting Ph: 519-685-8122 |Fax: 519-685-8279 London, Ontario |N6A5W9 800 Commissioners Rd E. Victoria Hospital, Room B10-123A MOLECULAR GENETICS LABORATORY Clinical Diagnostics andFamily History: Sample Collection: Lab Use Only: Sample Requirements can befound at https://www.lhsc.on.ca/palm/molecular/specimen.html#main-content Requisitions can be found at https://www.lhsc.on.ca/palm/forms/requisitions.html#moldx - Biochemical Genetics Hematologic Oncology - Atypical Uremic Hemolytic Syndrome - Epilepsy - Hereditary CancerPanel (HCP) - Please usethededicated requisitions for the following test requests: Ph: 519-685-8122 | Fax: 519-685-8279 London, Ontario |N6A 5W9 800 Commissioners Rd. E. Victoria Hospital, Room B10-123A Molecular Genetics Laboratory Requisition for DNA Testing NGS PANELS Name of index case inthefamily RefSeq:NM: Gene: Relationship to thispatient: Date drawn: Date of Birth: Notes: Received date: Charcot MarieTooth Nuclear encoded genes: Mitochondrial GenomeandDepletion andIntegrity -Individualselections Mitochondrial Genome andDepletion/Integrity Panel Mitochondrial encoded genes: Charcot MarieTooth -Individualselections (slides preferred) Formalin fixed paraffin embeddedtissue(FFPE) Fresh/Frozen Tissue ug DNA (100ngto 1ug): EDTA bonemarrow (lavender top)(min. 2mlat room temp) Referral to anoutside laboratory RNA Banking DNA Banking FamilyCarrier testing/Known Mutation EDTA blood(lavender top)(min. 2mlat room temp) Prenatal Diagnosis Diagnostic Testing: Other: SIGMAR1 SBF1 PLEKHG5 MPZ LMNA TRIM2 HSPB8 GARS DNM2 BSCL2 AARS SBF1, SBF2,SCO2, SELRC1, SEPT9, SETX,SGPL1,SH3TC2, SIGMAR1,SLC12A6, SLC9A3R1, SORD, SPG11,SPTLC1, SURF1,TFG, VCP, TRIM2,TRPV4, TTR, VRK1,WARS, YARS MARS, MCM3AP, MFN2,MME,MORC2, MPV17, MPZ, MTMR2,NAGLU, PDK3,PDXK, NDRG1, NEFH,NEFL, PLEKHG5,PMP2,PMP22,PNKP, PRPS1,PRX,PTRH2, RAB7A, DYNC1H1, EGR2, FBLN5,FGD4, FIG4,GARS, GDAP1, GJB1,GNB4,HARS, HINT1,HSPB1,HSPB3,HSPB8,IGHMBP2,INF2,JAG1, KARS, KIF1B, LITAF, KIF5A, LRSAM1, LMNA, AARS, ABHD12,AIFM1,ARHGEF10,ARHGEF28,ATP1A1, ATP7A, BAG3, DGAT2, DCTN2, BSCL2,C1orf194,CNTNAP1,DCTN1, DNM2,DNMT1,DRP2, DHTKD1,DNAJB2, Charcot MarieTooth, HNPP-Comprehensive(8 OPA3 APTX SUCLG1, TK2,TWNK,TYMP Nuclear encoded genes: TRNI, TRNK,TRNL1,TRNL2,TRNM,TRNN,TRNP, TRNR,TRNS,TRNS2,TRNT, TRNQ, TRNV, TRNW, TRNY Mitochondrial encoded genes: Mitochondrial GenomeandDepletion/Integrity Panel (56) TRNS2 TRNL1 TRNC ND3 ATP6 TK2 Unaffected Affected

(isoform A&B) ( ) YYYY/MM/DD (INCLUDES DELETION/DUPLICATION ANALYSIS)

SLC12A6 SBF2 PMP2 MTMR2 LRSAM1 IGHMBP2 GDAP1 DNMT1 C1orf194 ABHD12 TRPV4 TRNT TRNL2 TRND ND4 ATP8 TWNK POLG DGUOK APTX, DGUOK,DNA2,FBXL4, GFER,MGME1,MPV17, OPA1, OPA3 (isoform A&B),POLG, POLG2, RRM2B, SLC25A4, SPG7(isoform 1&2),SUCLA2,

(provide tissue source): tissue (provide

ATP6, ATP8, COX1, COX2, COX3, CYTB, TRNC, ND5,ND6,RNR1,RNR2,TRNA, TRND, ND1,ND2,ND3,ND4,ND4L, TRNE,TRNF, TRNG,TRNH, (C10 orf2) Mutation: (include copy of report): of copy (include

(must specify lab): specify (must SLC9A3R1 SCO2 PMP22 NAGLU MARS INF2 GJB1 DRP2 CNTNAP1 AIFM1 TTR TTR TRNV TRNM TRNE ND4L COX1 TYMP POLG2 DNA2

(Individual selections available for out-of-province requests only exceptTTR) SPTLC1 and 7) SORD SELRC1 PNKP NDRG1 MCM3AP JAG1 GNB4 DYNC1H1 DCTN1 ARHGEF10 VCP TRNW TRNN TRNF ND5 COX2 RRM2B FBXL4

Referring Physician: INCOMPLETE REQUESTS WILLBEBANKED Patient Information: Request for Expedited Result: Test Requests: AUTHORIZED SIGNATURE ISREQUIRED Telephone: Telephone: Address: E-mail address: Address: Name: Signature: Physician name(print): Medical intervention Medical intervention adjacent to theitem of interest. panelssub- orindividualgenes maybeselected usingthecheckbox Use attached menuto select panels orindividualgenes. Panels, CC report to: Se Address: Birthdate: Name: Health Card Number: x: SPG11 SEPT9 PRPS1 NEFH MFN2 KARS HARS EGR2 DCTN2 ARHGEF28 VRK1 Pregnancy Patient Identifier: TRNY TRNP TRNG ND6 COX3 SLC25A4 GFER

(Individual selections available for out-of-province requests only) aeFemale Male : YY/MM/DD) (L.M.P., SPTLC1 SETX PRX NEFL MME KIF1B HINT1 FBLN5 DGAT2 ATP1A1 WARS TRNQ TRNH RNR1 CYTB SPG7 MGME1 (specify with date): with (specify Pathology and LaboratoryMedicine

(isoform A&B) Fax: Fax: SURF1 SGPL1 PTRH2 PDK3 MORC2 KIF5A HSPB1 FGD4 DHTKD1 ATP7A YARS TRNR TRNI RNR2 ND1 SUCLA2 MPV17 NGSMGL(12/04/2017) (08/17/2021) TFG SH3TC2 RAB7A PDXK MPV17 LITAF HSPB3 FIG4 DNAJB2 BAG3 TRNS TRNK TRNA ND2 SUCLG1 OPA1 PagePage 1 3of of 5 3 LondonLondon Health Sciences Sciences Centre Centre – Molecular– (Molecular Diagnostics Genetics) Reason for Referral: Requisition for DNATesting Ph: 519-685-8122 |Fax: 519-685-8279 London, Ontario |N6A5W9 800 Commissioners Rd E. Victoria Hospital, Room B10-123A MOLECULAR GENETICS LABORATORY Clinical Diagnostics andFamily History: Sample Collection: Lab Use Only: Ph: 519-685-8122 | Fax: 519-685-8279 London, Ontario |N6A 5W9 800 Commissioners Rd. E. Victoria Hospital, Room B10-123A Molecular Genetics Laboratory Requisition for DNA Testing TARGETED ASSAYS SINGLE GENES BY NGS NGS PANELS Name of index case inthefamily RefSeq:NM: Gene: Relationship to thispatient: Date drawn: Date of Birth: Notes: Received date: Urea Cycle Disorders -Individualselections Urea Cycle Disorders Lysosomal Storage Disorders Lysosomal Storage Disorders -Individualselections (slides preferred) Formalin fixed paraffin embeddedtissue(FFPE) Fresh/Frozen Tissue ug DNA (100ngto 1ug): EDTA bonemarrow (lavender top)(min. 2mlat room temp) Referral to anoutside laboratory RNA Banking DNA Banking FamilyCarrier testing/Known Mutation EDTA blood(lavender top)(min. 2mlat room temp) Prenatal Diagnosis Diagnostic Testing: Other: SUMF1 NEU1 LAMP2 GRN GALNS CTNS AGA SUMF1, TPP1 GUSB, HEXB, HEXA, HGSNAT, HYAL1, IDS,IDUA, LAMP2,LIPA, MAN2B1,MANBA, MCOLN1, MFSD8, NAGA, NAGLU, NEU1,NPC1,NPC2,PPT1, PSAP, SGSH,SLC17A5, SMPD1, AGA, ARSA, ARSB, ASAH1, CTSD, CTSA, CLN3,CLN5,CLN6,CLN8,CTNS, GALC, FUCA1,GAA, GNPTAB, GLB1,GM2A, DNAJC5, CTSK, GALNS,GBA, GLA, GNPTG, GNS,GRN, Lysosomal Storage Disorders (50) F5 F2 CFTR TTR SPTLC1 SCN4A NOTCH3 MECP2 GJB2 (CX26)/GJB6(CX30) ACADM OTC ARG1 CPS1,GLUD1, ASS1,CA5A, AGR1, ASL, GLUL, NAGS, OTC, SLC25A2, SLC25A13, SLC25A15, SLC7A7 Urea Cycle Disorders Panel (13) Unaffected Affected -Factor (Mass VLeiden(F5:p.R534Q) Array) -Prothrombin G20210A(F2:c.97G>A)(Mass Array) -Amyloidosis - Cystic Fibrosis -70mutation screen (Mass Array) ( ) YYYY/MM/DD - RETT Syndrome -RETT - Paramyotonia Congenita - Hereditary Neuropathy Sensory -MediumChainAcylCoADehydrogenase (MCAD) - CADASIL (INCLUDES DELETION/DUPLICATION ANALYSIS) TPP1 NPC1 LIPA GUSB GBA CTSA ARSA SLC25A2 ASL (provide tissue source): tissue (provide

(INCLUDES DELETION/DUPLICATION ANALYSIS) Mutation:

(include copy of report): of copy (include -Recessive Deafness

(must specify lab): specify (must NPC2 MAN2B1 HEXA GLA CTSD ARSB SLC25A13 ASS1

PPT1 MANBA HEXB GLB1 CTSK ASAH1 SLC25A15 CA5A

Referring Physician: INCOMPLETE REQUESTS WILLBEBANKED Patient Information: Request for Expedited Result: Test Requests: AUTHORIZED SIGNATURE ISREQUIRED Telephone: Telephone: Address: E-mail address: Address: Name: Signature: Physician name(print): Medical intervention Medical intervention adjacent to theitem of interest. panelssub- orindividualgenes maybeselected usingthecheckbox Use attached menuto select panels orindividualgenes. Panels, CC report to: Se Address: Birthdate: Name: Health Card Number: PSAP MCOLN1 HGSNAT GM2A DNAJC5 CLN3 x: SLC7A7 CPS1 Pregnancy Patient Identifier: tissue contamination studies (fragment analysis) MCC/Identity testing HFE OTC CLN3 CLN2-TPP1 CTNS ARSA ARG1 NPC (NPC1/NPC2) -Hemochromatosis p.C282Y andp.H63D(Mass Array) -OrnithineTranscarbamylase aeFemale Male -Batten Disease -Cystinosis -Metachromatic Leukodystrophy -Arginase Deficiency : YY/MM/DD) (L.M.P., -Batten Disease SGSH MFSD8 HYAL1 GNPTAB FUCA1 CLN5 GLUD1 (specify with date): with (specify Pathology and LaboratoryMedicine -Niemann-PickDisease -Maternal cell contamination/ Fax: Fax: SLC17A5 NAGA IDS GNPTG GAA CLN6 GLUL NGSMGL(12/04/2017) (08/17/2021) SMPD1 NAGLU IDUA GNS GALC CLN8 NAGS