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Home , Apert syndrome, Campomelic dysplasia, Currarino syndrome, Cutis laxa, Dock6, Feingold syndrome

REQUISITION

1-844-363-4357· Ask.@LifeLabs.com Schillingallee 68 · 18057 Rostock Germany Attention Patient: Please visit your nearest LifeLabs or CML Healthcare Patient Service Centre for sample collection LL: K012-01/ CML: CEN CONTRACT #

Report to Physician Billing # LifeLabs Demographic Ordering Physician Name Label 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 1/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 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 , 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

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

Testing Instructions: (ex: Reflex order) ** PLEASE INCLUDE A COPY OF REQUISITION WITH SAMPLES **

Page 2/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 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), Sequencing (S), and/or Deletion/Duplication (D) analysis

Disorders of Skin, Teeth, & Hair NGS Panels:

S Congenital panel (ABCA12, ALOX12B, ALOXE3, CERS3, CYP4F22, LIPN, NIPAL4, PNPLA1, TGM1) S panel (COL17A1, LAMA3, LAMB3, LAMC2) Single : H D S inversa familial type 3 (PSEN1) D S Epidermolytic palmoplantar (KRT9) Erythroderma, congenital, with , hypotrichosis and D S Adams-Oliver syndrome type 1 (ARHGAP31) D S hyper IgE (DSG1) D S Adams-Oliver syndrome type 2 (DOCK6) D S variabilis et progressiva (GJB3) D S Adams-Oliver syndrome type 3 (RBPJ) D S Erythrokeratodermia variabilis et progressiva (GJB4) D S Ankyloblepharon-ectodermal defects-cleft lip/palate (TP63) D S (PORCN) D S oculocutaneous nonsyndromic (SLC24A5) D S type 1 (MYO5A) H D S Albinism, oculocutaneous type 1A (TYR) D S Griscelli syndrome type 3 (MLPH) H D S Albinism, oculocutaneous type 1B (TYR) D S Haim-Munk syndrome (CTSC) H D S Albinism, oculocutaneous type 2 (OCA2) D S Hyaline fibromatosis syndrome (ANTXR2) H D S Albinism, oculocutaneous type 2 (OCA2) D S Hypotrichosis Type 7 (LIPH) D S Albinism, oculocutaneous type 3 (TYRP1) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (ALOX12B) H D S Albinism, oculocutaneous type 4 (SLC45A2) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (ALOXE3) D S Albinism oculocutaneous type 5 (C10ORF11) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (NIPAL4) H D S Amelogenesis imperfecta (DLX3) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (TGM1) D S Autosomal dominant woolly hair with hypotrichosis (KRT71) D S Ichthyosis congenita, Harlequin fetus type (ABCA12) D S Autosomal dominant woolly hair with hypotrichosis (KRT74) D S Ichthyosis congenital, autosomal recessive type 9 (CERS3) D S Bjornstad syndrome (BCS1L) D S Ichthyosis congenital, autosomal recessive PNPLA1 related (PNPLA1) Cerebral dysgenesis, neuropathy, ichthyosis, palmoplantar keratoderma syndrome D S (SNAP29) D S Ichthyosis follicularis, atricia, and syndrome (MBTPS2) D S Chediak-Higashi syndrome (LYST) D S Ichthyosis prematurity syndrome (SLC27A4) D S CHIME syndrome (PIGL) H D S (FLG) D S Corneal intraepithelial dyskeratosis and (NLRP1) D S Ichthyosis, bullous type (KRT2) D S and dental anomalies (IL11RA) D S Ichthyosis, lamellar type 1 (TGM1) D S Cutis laxa type 1B (EFEMP2) D S Ichthyosis, lamellar type 2 (ABCA12) D S Cutis laxa type 2B (PYCR1) D S Ichthyosis, lamellar type 3 (CYP4F22) D S Cutis laxa type 3B (PYCR1) D S Ichthyosis, lamellar type 4 (LIPN) D S Cutis laxa, autosomal dominant (ELN) D S Ichthyosis, spastic quadriplegia, and mental retardation (ELOVL4) H D S Dermatitis, atopic type 2 (FLG) D S Ichthyosis, X-linked (STS) D S , autosomal dominant type 1 (TERC) D S type 2 (IKBKG) D S Dyskeratosis congenita, autosomal dominant type 1 (TERT) D S Keratosis follicularis spinulosa declavans, X-linked (MBTPS2) D S Dyskeratosis congenita, autosomal recessive type 1 (NOP10) D S Keratosis palmoplantaris striata type 1 (DSG1) D S Dyskeratosis congenita, autosomal recessive type 2 (NHP2) D S Keratosis palmoplantaris striata type 2 (DSP) D S Dyskeratosis congenita, autosomal recessive type 5 (RTEL1) D S (FERMT1) D S Dyskeratosis congenita, X-linked (DKC1) D S Kindler syndrome (FBLIM1) D S Ectodermal dysplasia, , and macular dystrophy (CDH3) D S Laryngoonychocutaneous syndrome (LAMA3) H D S Ectodermal dysplasia, hidrotic (GJB6) D S (SPRED1) D S Ectodermal dysplasia, hypohidrotic, autosomal recessive (EDAR) D S Mal de Meleda (SLURP1) D S Ectodermal dysplasia, hypohidrotic, autosomal recessive (EDARADD) D S (SPINK5) D S Ectodermal dysplasia, hypohidrotic, with immune deficiency (IKBKG) D S Oculodentodigital dysplasia (GJA1) D S Ectodermal dysplasia, hypohidrotic, X-linked (EDA) D S Odontoonychodermal dysplasia (WNT10A) H D S Epidermal , somatic (NRAS) D S Olmsted syndrome (TRPV3) D S Epidermolysis bullosa dystrophica (COL7A1) D S type 1 (KRT6A) D S Epidermolysis bullosa, junctional (COL17A1) D S Papillon-Lefevre syndrome (CTSC) D S Epidermolysis bullosa, junctional (LAMB3) D S Peeling skin syndrome (CDSN) D S Epidermolysis bullosa, junctional (LAMC2) D S Peeling skin syndrome type A (CHST8) D S Epidermolysis bullosa, junctional LAMA3 (LAMA3) D S Peeling skin syndrome, acral type (TGM5) D S Epidermolysis bullosa junctionalis with pyloric atresia (ITGA6) D S type 3, disseminated superficial actinic (MVK) D S Epidermolysis bullosa junctionalis with pyloric atresia (ITGB4) D S Porphyria cutanea tarda (UROD) D S Epidermolysis bullosa, lethal acantholytic (DSP) D S Psoriasis susceptibility type 11 (IL12B) D S Epidermolysis bullosa simplex (KRT5) D S Psoriasis, generalized pustular (IL36RN) D S Epidermolysis bullosa simplex (KRT14) D S Pyogenic sterile arthritis, pyoderma gangrenosum, and acne (PSTPIP1) D S Epidermolysis bullosa simplex, autosomal recessive (DST) D S Rapp-Hodgkin syndrome (TP63) D S Epidermolytic (KRT1) D S , lethal (ZMPSTE24) D S Epidermolytic hyperkeratosis (KRT10) D S Rothmund-Thomson syndrome (RECQL4) Page 3/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): Disorders of Skin, Teeth, & Hair (continued)

D S Skin fragility-woolly hair syndrome (DSP) D S Tylosis with esophageal cancer (RHBDF2) D S Skin hair eye pigmentation 6 (SLC24A4) D S UV-sensitive syndrome 3 (UVSSA) D S Telangiectasia hereditary hemorrhagic type 5 (GDF2) D S Vohwinkel syndrome with ichthyosis (LOR) D S Telangiectasia, hereditary hemorrhagic, of Rendu, Osler, and Weber Type 1 (ENG) D S type 1 (PAX3) Telangiectasia, hereditary hemorrhagic, of Rendu, Osler, and Weber Type 2 D S (ACVRL1) D S Waardenburg syndrome type 2E (SOX10) D S Tooth agenesis, selective type 1 (MSX1) D S Waardenburg syndrome type 4C (SOX10) D S Tooth agenesis, selective type 3 (PAX9) D S Witkop syndrome (MSX1) H D S Trichodontoosseous syndrome (DLX3) D S , group A (XPA) D S (ERCC2) D S Xeroderma pigmentosum, group C (XPC) D S Trichothiodystrophy (ERCC3) D S Xeroderma pigmentosum, group D (ERCC2) D S Trichothiodystrophy (GTF2H5) D S Xeroderma pigmentosum, group G (ERCC5) D S Trichothiodystrophy, nonphotosensitive type 1 (MPLKIP) D S Xeroderma pigmentosum, variant type (POLH) Disorders of Bone & Connective Tissue

NGS Panels:

D S Ehlers-Danlos syndrome panel (COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, FKBP14, PLOD1, TNXB) D S and related disorders panel (ACTA2,COL3A1,COL5A1,COL5A2,FBN1,FBN2,MYH11,SLC2A10,SMAD3,TGFBR1,TGFBR2) S Metaphyseal dysplasia panel (ANKH, CDKN1C, FLNA, MMP9, MMP13, NKX3-2, RMRP, RUNX2) D S Multiple epiphyseal dysplasia panel (COL2A1,COL9A1, COL9A2, COL9A3, COMP, MATN3, SLC6A2) D S panel (COL1A1, COL1A2, IFITM5) D S Osteogenesis imperfecta, autosomal recessive panel (BMP1, CRTAP, FKBP10, LEPRE1, PLOD2, PPIB, SERPINH1, SP7) S panel (CA2, CLCN7, LRP5, OSTM1, PLEKHM1, SNX10, TCIRG1, TNFSF11, TNFRSF11A) D S panel (ATR, RBBP8, CENPJ, CEP152, CEP63, ATRIP) Single genes:

D S 3 M syndrome type 1 (CUL7) D S Cleidocranial dysplasia (RUNX2) D S 3 M syndrome type 2 (OBSL1) H D S Craniofacial-skeletal-dermatologic dysplasia (FGFR2) D S Achondrogenesis, type IA (TRIP11) D S Craniofacial and neuro-developmental abnormalities (DISP1) D S Achondrogenesis, type IB (SLC26A2) D S Craniometaphyseal dysplasia (ANKH) D S (FGFR3) D S Craniosynostosis type 2 (MSX2) D S Acrodermatitis enteropathica (SLC39A4) D S Craniosynostosis type 3 (TCF12) D S Acrodysostosis 2 (PDE4D) D S Craniosynostosis and dental anomalies (IL11RA) D S Acrofacial dysostosis 1, Nager type (SF3B4) D S with (FGFR3) D S Acromesomelic dysplasia, Maroteaux type (NPR2) D S Diaphyseal medullary stenosis with malignant fibrous histiocytoma (MTAP) H D S Antley-Bixler syndrome (FGFR2) D S Dyssegmental dysplasia, Silverman-Handmaker type (HSPG2) D S Alazami syndrome (LARP7) D S Ehlers-Danlos syndrome type 1/2 (COL5A1) H D S (FGFR2) D S Ehlers-Danlos syndrome type 1/2 (COL5A2) D S Arthropathy of childhood, progressive pseudorheumatoid (WISP3) D S Ehlers-Danlos syndrome type 3 (TNXB) D S Atelosteogenesis type 1 (FLNB) H D S Ehlers-Danlos syndrome type 3 (COL3A1) D S Atelosteogenesis type 3 (FLNB) H D S Ehlers-Danlos syndrome type 4 (COL3A1) D S Baller-Gerold syndrome (RECQL4) D S Ehlers-Danlos syndrome type 4 (COL5A1) H D S Beare-Stevenson cutis gyrata syndrome (FGFR2) D S Ehlers-Danlos syndrome type 6 (PLOD1) H D S Bent bone dysplasia syndrome (FGFR2) H D S Ehlers-Danlos syndrome type 7A (COL1A1) D S type A2 (BMPR1B) D S Ehlers-Danlos syndrome type 7B (COL1A2) D S Brachydactyly type A2 (BMP2) D S Ehlers-Danlos syndrome type 7C (ADAMTS2) Ehlers-Danlos syndrome with progressive kyphoscoliosis, myopathy, and D S Brachydactyly type B1 (ROR2) D S (FKBP14) D S Brachydactyly type E1 (HOXD13) D S Ehlers-Danlos syndrome, progeroid type 1 (B4GALT7) D S Brachydactyly, type A1 (GDF5) D S Exostoses, multiple, type 1 (EXT1) D S Brachydactyly-mental retardation syndrome (HDAC4) H D S Fibrochondrogenesis 2 (COL11A2) D S Brachydactyly- syndrome (HOXD13) D S Fibrodysplasia ossificans progressiva (ACVR1) Fibular aplasia or hypoplasia, femoral bowing and poly-, syn-, and Buschke-Ollendorff syndrome (LEMD3) D S D S (WNT7A) D S C syndrome (CD96) D S Floating-Harbor syndrome (SRCAP) D S (SOX9) D S Frank-ter Haar syndrome (SH3PXD2B) D S Camurati-Engelmann disease (TGFB1) D S Frontonasal dysplasia type 1 (ALX3) D S Chondrodysplasia punctata, X-linked recessive (ARSE) D S Geleophysic dysplasia (ADAMTSL2) D S Chondrosarcoma (EXT1)

Page 4/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): Disorders of Bone & Connective Tissue (continued)

D S Greig cephalopolysyndactyly syndrome (GLI3) D S Otospondylomegaepiphyseal dysplasia (COL11A2) D S Gracile bone dysplasia (FAM111A) D S Parietal foramina type 1 (MSX2) D S Holt-Oram syndrome (TBX5) H D S (FGFR2) D S Holt-Oram syndrome (SALL4) D S Postaxial acrofacial dysostosis (DHODH) D S Hypertrophic osteoarthropathy type 1 (HPGD)) D S Pseudoachondroplasia (COMP) D S Hypertrophic osteoarthropathy type 2 (SLCO2A1) D S Pycnodysostosis (CTSK) D S Jackson-Weiss syndrome (FGFR2) D S Radioulnar synostosis, FGFRL1 related (FGFRL1) D S Klippel-Feil syndrome type 1, autosomal dominant (GDF6) D S RAPADILINO syndrome (RECQL4) D S Klippel-Feil syndrome type 3, autosomal dominant (GDF3) D S Rhizomelic chondrodysplasia punctata type 2 (GNPAT) D S Langer-Giedion syndrome (EXT1) D S Rhizomelic chondrodysplasia punctata type 3 (AGPS) D S Langer-Giedion syndrome (TRPS1) D S Roberts syndrome (ESCO2) D S (FLNB) D S (ROR2) D S Loeys-Dietz syndrome type 1A (TGFBR1) D S Robinow syndrome (WNT5A) D S Loeys-Dietz syndrome type 1B (TGFBR2) D S Rubinstein-Taybi syndrome (CREBBP) D S Loeys-Dietz syndrome type 1C (SMAD3) D S Rubinstein-Taybi syndrome (EP300) D S Loeys-Dietz syndrome type 2A (TGFBR1) D S Saethre-Chotzen syndrome (TWIST1) D S Loeys-Dietz syndrome type 2B (TGFBR2) H D S Saethre-Chotzen syndrome (FGFR2) D S Mandibulofacial dysostosis with (EFTUD2) H D S , maxillary retrusion, and mental retardation (FGFR2) H D S Marfan syndrome (FBN1) D S SC syndrome (ESCO2) D S Meier-Gorlin syndrome 1 (ORC1) D S Seckel syndrome type 1 (ATR) D S Meier-Gorlin syndrome 4 (CDT1) D S Seckel syndrome type 2 (RBBP8) D S Metaphyseal anadysplasia type 1 (MMP13) D S Seckel syndrome type 4 (CENPJ) D S Metaphyseal anadysplasia type 2 (MMP9) D S Seckel syndrome type 5 (CEP152) D S Metaphyseal dysplasia without hypotrichosis (RMRP) D S Seckel syndrome type 6 (CEP63) D S Microcephalic osteodysplastic primordial type 1 (RNU4ATAC) D S Seckel syndrome type 8 (ATRIP) D S Microcephalic osteodysplastic type 2 (PCNT) D S syndrome (SHOX) D S Multicentric carpotarsal osteolysis syndrome (MAFB) D S Short stature syndrome (GHR) D S Multicentric osteolysis, nodulosis, and arthropathy (MMP2) D S Short- thoracic dysplasia type 4 with or without (TTC21B) D S Multiple epiphyseal dysplasia type 3 (COL9A3) D S Short-rib thoracic dysplasia type 6 with or without polydactyly (NEK1) D S Multiple epiphyseal dysplasia type 5 (MATN3) D S Shprintzen-Goldberg syndrome (SKI) D S Nail-Patella syndrome (LMX1B) D S Split-hand/foot malformation type 6 (WNT10B) D S Omodysplasia type 1 (GPC6) D S Split-hand/foot malformation type 1 with sensorineural hearing loss (DLX5) D S Opsismodysplasia (INPPL1) D S Spondylocarpotarsal synostosis syndrome (FLNB) D S Orofacial cleft type 5 (MSX1) D S Spondylocostal dysostosis, autosomal recessive type 1 (DLL3) D S Orofacial cleft type 11 (BMP4) D S Spondylocostal dysostosis, autosomal recessive type 2 (MESP2) H D S Osteogenesis imperfecta (COL1A1) D S Spondylocostal dysostosis, autosomal recessive type 3 (LFNG) D S Osteogenesis imperfecta (COL1A2) D S Spondyloenchondrodysplasia with immune dysregulation (ACP5) D S Osteogenesis imperfecta type 5 (IFITM5) D S Spondyloepimetaphyseal dysplasia, MATN3-related (MATN3) D S Osteogenesis imperfecta type 7 (CRTAP) D S Spondyloepimetaphyseal dysplasia, Missouri type (MMP13) D S Osteogenesis imperfecta type 8 (LEPRE1) D S Spondyloepiphyseal dysplasia with congenital joint dislocations (CHST3) D S Osteogenesis imperfecta type 9 (PPIB) D S Spondylo-megaepiphyseal-metaphyseal dysplasia (NKX3-2) D S Osteogenesis imperfecta, type 10 (SERPINH1) D S Spondylometaepiphyseal dysplasia, short limb-hand type (DDR2) D S Osteogenesis imperfecta type 11 (FKBP10) D S Stuve-Wiedemann syndrome (LIFR) D S Osteogenesis imperfecta, type 12 (SP7) D S Terminal osseous dysplasis (FLNA) D S Osteogenesis imperfecta, type 13 (BMP1) D S Tetraamelia, autosomal recessive (WNT3) D S Osteogenesis imperfecta, type 14 (TMEM38B) D S Treacher Collins syndrome type I (TCOF1) D S Osteogenesis imperfecta with congenital joint (PLOD2) D S Treacher Collins syndrome type 2 (POLR1D) D S Osteomyelitis, sterile multifocal, with periostitis and pustulosis (IL1RN) D S Treacher Collins syndrome type 3 (POLR1C) D S Osteopathia striata with cranial sclerosis (AMER1) D S Trichorhinophalangeal syndrome, type I (TRPS1) D S Osteopetrosis of infancy, malignant (SNX10) D S Ulna and fibula, absence of, with severe limb deficiency (WNT7A) D S Osteopetrosis, autosomal dominant type 1 (CLCN7) D S Ulnar-Mammary syndrome (TBX3) D S Osteopetrosis, autosomal recessive type 1 (TCIRG1) D S Van den Ende-Gupta syndrome (SCARF2) D S Osteopetrosis, autosomal recessive type 2 (TNFSF11) D S (GRHL3) D S Osteopetrosis, autosomal recessive type 3 (CA2) D S (NSD1) D S Osteopetrosis, autosomal recessive type 4 (CLCN7) D S Weaver syndrome (EZH2) D S Osteopetrosis, autosomal recessive type 5 (OSTM1) D S Weill-Marchesani syndrome type 3 (LTBP2) D S Osteopetrosis, autosomal recessive type 6 (PLEKHM1) D S Winchester Syndrome (MMP14) D S Osteopetrosis, autosomal recessive type 7 (TNFRSF11A) D S Wolcott-Rallison syndrome (EIF2AK3) H D S Osteoporosis pseudoglioma syndrome (LRP5) D S Wolcott-Rallison syndrome (EIF2AK3)

Page 5/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): Disorders of the

NGS Panels: Generalized epilepsy with febrile seizures D S panel (GABRD, GABRG2, SCN1A, SCN1B, SCN2A, SCN9A) D S Hemophagocytic Lymphohistiocytosis panel (PRF1, UNC13D, STX11, STXBP2) D S Periodic fever syndrome panel (ELANE, LPIN2, MEFV, MVK, NLRP3, PSTPIP1, TNFRSF1A) Single genes:

D S Atypical Mycobacterial infection (IKBKG) D S Immunodeficiency type 14 (PIK3CD)

D S Atypical Mycobacterial infection (IFNGR2) D S Autoimmune lymphoproliferative syndrome type 1A (FAS)

D S Atypical Mycobacterial infection (IL12RB1) D S Autoimmune lymphoproliferative syndrome type 1B (FASLG)

D S Atypical Mycobacterial infection (IL12RB2) D S Autoimmune lymphoproliferative syndrome type 2A (CASP10)

D S Atypical Mycobacterial infection (STAT1) D S Autoimmune lymphoproliferative syndrome type 2B (CASP8)

D S Autoimmune polyendocrinopathy syndrome type I (AIRE) H D S Autoimmune lymphoproliferative syndrome type 4 (NRAS)

D S Bare lymphocyte syndrome, type 2 (RFXANK) D S Immunodeficiency, isolated (IKBKG) D S C2 deficiency (C2) H D S Immunodeficiency with natural killer cell deficiency (MCM4) D S C3 deficiency (C3) D S Immunodeficiency, X-linked with hyper-IgM (CD40LG) Immunodeficiency, X-linked, with magnesium defect, Epstein-Barr virus D S D S C7 deficiency (C7) infection and neoplasia (MAGT1) Immunodysregulation, polyendocrinopathy, and enteropathy, X-linked D S Celiac disease, susceptibility to (HLA-DQA1) DS (FOXP3) D S Celiac disease, susceptibility to (HLA-DQB1) D S Immunological disorder, PECAM1-related (PECAM1) D S Chediak-Higashi syndrome (LYST) D S Interleukin 2 receptor deficiency (IL2RA) D S Cold autoinflammatory syndrome type 2 (NLRP12) D S Invasive pneumococcal disease, recurrent isolated type 2 (IKBKG) Granulomatous disease, chronic, autosomal recessive, cytochrome b-negative D S (CYBA) D S Langerhans cell histiocytosis, ARAF-related (ARAF) Chronic granulomatous disease, autosomal recessive, cytochrome b- positive, type D S 1 (NCF1) H D S LIG4 syndrome (LIG4) Chronic granulomatous disease, autosomal recessive, cytochrome b- positive, type D S 2 (NCF2) D S Major histocompatibility comples 1 deficiency (MR1) Chronic granulomatous disease, autosomal recessive, cytochrome b- positive, type D S D S 3 (NCF4) Mediterranean fever (MEFV) D S Chronic granulomatous disease, X-linked (CYBB) D S Muckle-wells syndrome (NLRP3) D S Combined cellular and humoral immune defects with granulomas (RAG2) D S Mycobacterial infection, atypical, familial disseminated (IFNGR1) Combined immunodeficiency, B cell-negative, T cell-negative, NK cell positive D S (RAG2) D S Omenn syndrome (RAG2) D S Combined immunodeficiency, X-linked, moderate (IL2RG) D S Omenn syndrome (DCLRE1C) D S Diarrhea type 2 with microvillus atrophy (MYO5B) D S Periodic fever autosomal dominant (TNFRSF1A) Erythroderma, congenital, with palmoplantar keratoderma, hypotrichosis and hyper D S IgE (DSG1) D S Reticular dysgenesis (AK2) D S Hemophagocytic lymphohistiocytosis type 1 (PRF1) D S , susceptibility to (AFF3) D S Hemophagocytic lymphohistiocytosis type 3 (UNC13D) D S Rheumatoid arthritis, TNFAIP3-related (TNFAIP3) D S Hemophagocytic lymphohistiocytosis type 4 (STX11) D S Schimke immunoosseous dysplasia (SMARCAL1) Severe combined immunodeficiency autosomal recessive T negative B D S Hemophagocytic lymphohistiocytosis type 5 (STXBP2) D S positive type (JAK3) D S Herpes simplex encephalitis type 2, susceptibility to (TLR3) D S Severe combined immunodeficiency due to ADA deficiency (ADA) Severe combined immunodeficiency with microcephaly, growth retardation, D S Hyper-IgE recurrent infection syndrome (STAT3) D S and sensitivity to (NHEJ1) D S Hyper-IgE recurrent infection syndrome, autosomal recessive (DOCK8) D S Severe combined immunodeficiency, B cell-negative (RAG1) D S Hypereosinophilic syndrome, idiopathic, resistant to imatinib (PDGFRA) D S Systemic erythematosus (DNASE1) D S Immunodeficiency common variable 1 (ICOS) D S Systemic lupus erythematosus, susceptibility to (ITGAM) D S Immunodeficiency, common variable type 7 (CR2) D S -associated multiple (NLRP1) D S Immunodeficiency type 2, with hyper-IgM (AICDA) D S Vitiligo-associated multiple autoimmune disease (NLRP1) D S Immunodeficiency type 5, with hyper IgM (UNG)

Page 6/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): Other

NGS Panels:

S panel (TPM2, MYBPC1, MYH3, TNNT3, TNNI2, MYH8, FBN2) D S Cornelia de Lange syndrome panel (HDAC8, NIPBL, RAD21, SMC1A, SMC3) D S Neurofibromatosis panel (NF1, NF2, SPRED1) D S Noonan - CFC syndrome panel (BRAF, CBL, HRAS, MAP2K1, KRAS, MAP2K2, NF1, NRAS, RAF1, PTPN11, SHOC2, SOS1, SPRED1) Single genes:

D S 3MC1 syndrome (MASP1) H D S Bifid nose (FREM1) D S 3MC2 syndrome (COLEC11) D S (BLM) D S ADULT syndrome, split hand-foot malformation (TP63) D S Cantu syndrome (ABCC9) D S Arthrogryposis, distal type 1 (TPM2) D S CLOVE syndrome (PIK3CA) D S Arthrogryposis, distal type 1 (MYBPC1) D S Cole disease (ENPP1) D S Arthrogryposis, distal type 2A (MYH3) D S Club foot (PITX1) D S Arthrogryposis, distal type 2B (TNNT3) D S , type A (ERCC8) D S Arthrogryposis, distal type 2B (MYH3) D S Craniofrontonasal syndrome (EFNB1) D S Arthrogryposis, distal type 2B (TNNI2) D S Cornelia de Lange syndrome type 1 (NIPBL) D S Arthrogryposis, distal type 7 (MYH8) D S Cornelia de Lange syndrome type 2 (SMC1A) D S Arthrogryposis, distal type 9 (FBN2) H D S Cornelia de Lange syndrome type 3 (SMC3) D S Arthrogryposis, mental retardation and seizures (SLC35A3) D S Cornelia de Lange syndrome type 4 (RAD21) D S Arthrogryposis, renal dysfunction and cholestasis (VPS33B) D S Cornelia de Lange syndrome type 5 (HDAC8) D S Autoinflammation, lipodystrophy and dermatosis syndrome (PSMB8) D S (MNX1) D S Auriculocondylar syndrome (GNA13) D S Ectodactyly, ectodermal dysplasia, and cleft lip/palate syndrome 3 (TP63) Exocrine pancreatic insufficiency, dyserythropoietic anemia, and calvarial D S D S hyperostosis (COX412) Auriculocondylar syndrome type 2 (PLCB4) D S Faciogenital dysplasia, Aarskog-Scott syndrome (FGD1) D S (MYCN) D S Multiple pterygium syndrome lethal type (CHRND) D S Feingold syndrome type 2 (MIR17HG) D S Neurofibromatosis type 1 (NF1) D S Fetal akinesia deformation sequence (DOK7) D S Neurofibromatosis type 1 (SPRED1) D S Fetal akinesia deformation sequence (RAPSN) D S Neurofibromatosis type 2 (NF2) D S (GRIP1) D S like (SHOC2) D S Fraser syndrome (FREM2) D S Noonan syndrome type 1 (PTPN11) D S Frasier syndrome (WT1) D S Noonan syndrome type 3 (KRAS) D S Genitopatellar syndrome (KAT6B) D S Noonan syndrome type 4 (SOS1) D S Hamamy syndrome (IRX5) D S Noonan syndrome type 5 (RAF1) D S IMAGe syndrome (CDKN1C) H D S Noonan syndrome type 6 (NRAS) D S Jawad syndrome (RBBP8) H D S Noonan syndrome type 7 (BRAF) Noonan syndrome-like disorder with or without juvenile meylomonocytic D S D S KBG syndrome (ANKRD11) leukemia (CBL) D S (MGP) D S Oral-facial-digital syndrome type 1 (OFD1) D S LADD syndrome (FGF10) D S Oral-facial-digital syndrome type 4 (TCTN3) H D S LADD syndrome (FGFR2) D S Oral-facial-digital syndrome type 5 (DDX59) H D S LEOPARD syndrome 3 (BRAF) D S Orofaciodigital syndrome type 14 (C2CD3) D S Lethal congenital syndrome 4 (MYBPC1) D S Otofaciocervical syndrome (EYA1) D S Limb-mammary syndrome (TP63) D S Popliteal pterygium syndrome, lethal type (RIPK4) D S -distichiasis syndrome (FOXC2) D S Pterygium syndrome (CHRNG) D S Majeed syndrome (LPIN2) D S Syndactyly type 1 (HOXD13) D S Mandibuloacral dysplasia with type B lipodystrophy (ZMPSTE24) D S Syndactyly type 5 (HOXD13) H D S McKusick-Kaufman syndrome (MKKS) D S Toe syndactyly, telecanthus, and anogenital andrenal malformations (FAM58A) Multiple joint dislocations, short stature, craniofacial dysmorphism, and congenital D S D S defects (B3GAT3) VACTERL association (HOXD13) D S Multiple pterygium syndrome lethal type (CHRNA1) D S (EPG5)

Page 7/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 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), Repeat (R), Sequencing (S), and/or Deletion/Duplication (D) analysis

Tumors & Solid Malignancies

NGS Panels:

H D S BRCA panel (BRCA1, BRCA2) D S Breast ovarian cancer panel (ATM, BARD1, BRIP1, CDH1, CHEK2, MRE11A, MSH6, NBN, PALB2, PTEN, RAD51, RAD51C, STK11, TP53) D S Colon cancer and polyposis syndrome panel (APC, BMPR1A, ENG, EPCAM, FLCN, MLH1, MSH2, MSH3, MSH6, MUTYH, PMS1, PMS2, PTEN, SMAD4, STK11) D S Neurofibromatosis panel (NF1, NF2, SPRED1) D S Pheochromocytoma panel (MAX, PRKAR1A, SDHA, SDHAF2, SDHB, SDHC, SDHD, TMEM127, VHL) D S panel (TSC1, TSC2) Single genes:

D S Accelerated tumor formation, susceptibility to (MDM2) D S Glioma, MGMT related (MGMT) D S ACIN1 related tumors (ACIN1) D S Glioma, susceptibility to, somatic (IDH1) D S ARF-related tumors (ARF) D S Glioma, susceptibility to, somatic (IDH2) D S Ataxia-telangiectasia (ATM) D S Glioma, VN1R4-related (VN1R4) D S Basal cell carcinoma, somatic (SMO) D S Hemangioma capillary infantile, somatic (KDR) D S Basal cell nevus syndrome, Gorlin syndrome (PTCH1) D S Juvenile polyposis syndrome (BMPR1A) D Beckwith-Wiedemann syndrome (chr. 11p15) D S Juvenile polyposis syndrome (SMAD4) D S Beckwith-Wiedemann syndrome (CDKN1C) D S Juvenile polyposis/hereditary hemorrhagic telangiectasia syndrome (SMAD4) D S Beckwith-Wiedemann syndrome (NSD1) D S KIAA1107-related tumors (KIAA1107) D S Beckwith-Wiedemann syndrome (KCNQ1OT1) D S KEAP1-related tumors (KEAP1) D S Beckwith-Wiedemann syndrome (H19) D S Li-Fraumeni syndrome type 1 (TP53) D S Birt-Hogg-Dube syndrome (FLCN) D S Li-Fraumeni syndrome type 2 (CHEK2) D S Bloom syndrome (BLM) H DS cancer (BRAF) D S BRD4-related tumors (BRD4) D S Lung cancer (EEML4) H D S Breast cancer (PALB2) DS Lung cancer (EGFR) D S Breast cancer (BARD1) D S Lung cancer (ERBB2) H D S Breast-ovarian cancer (BRCA1) D S Lung cancer (MYCL) H D S Breast-ovarian cancer (BRCA2) D S Lung cancer, KIF5B-related (KIF5B) D S Breast-ovarian cancer (RAD51C) D S MAML3-related tumors (MAML3) D S Breast-ovarian cancer (RAD51D) D S Medulloblastoma, CIC related (CIC) D S CCND1-related tumors (CCND1) D S Medulloblastoma (CROCC) D S CCNE1-related tumors (CCNE1) D S Melanoma, cutaneous malignant (CDKN2A) D S CDH2-related tumors (CDH2) D S Melanoma, cutaneous malignant (CDKN2B) D S CDK6-related tumors (CDK6) D S Melanoma, cutaneous malignant (CDK4) D S CD74-related tumors (CD74) D S Melanoma, cutaneous malignant (MC1R) D S Chemotherapeutic drug resistance, NFE2L2-related (NFE2L2) D S Melanoma, cutaneous malignant (MITF) D S Chondrosarcoma (EXT1) D S Melanoma and non-melanoma skin cancers, GNG2-related (GNG2) D S Colorectal adenomatous polyposis (APC) D S MTOR- related tumors (MTOR) D S Colorectal adenomatous polyposis (MUTYH) D S Multiple endocrine neoplasia type 1 (MEN1) H D S Colorectal cancer, hereditary (NRAS) H D S Multiple endocrine neoplasia type 2A (RET) D S Colorectal cancer, hereditary nonpolyposis type 1 (MSH2) H D S Multiple endocrine neoplasia type 2B (RET) D S Colorectal cancer, hereditary nonpolyposis type 2 (MLH1) D S MYC-related tumors (MYC) D S Colorectal cancer, hereditary nonpolyposis type 4 (PMS2) D S Neuroblastoma (ALK) D S Colorectal cancer, hereditary nonpolyposis type 5 (MSH6) D S Neurofibromatosis type 1 (NF1) D S Colorectal cancer, hereditary nonpolyposis type 6 (TGFBR2) D S Neurofibromatosis type 1 (SPRED1) D S Colorectal cancer, hereditary nonpolyposis type 7 (MLH3) D S Neurofibromatosis type 2 (NF2) D S Colorectal cancer, hereditary nonpolyposis type 8 (EPCAM) D S Nonpolyposis colon cancer (PMS1) D S Colorectal cancer, somatic (FLCN) D S NFE2L2-related tumors (NFE2L2) D S Colorectal cancer, somatic (CTNNB1) D S NR1I2-related tumors (NR1I2) D S Colorectal cancer, somatic (MXRA5) H D S Pancreatic cancer (PALB2) D S Cowden disease (PTEN) D S Paragangliomas type 4 (SDHB) D S Cowden disease (AKT1) D S (DIS3L2) H D S Endometrial carcinoma (MSH3) D S Peutz-Jeghers syndrome (STK11) D S ERG related tumors (ERG) D S Pheochromocytoma type 1 (SDHA) D S Gastric cancer, hereditary diffuse (CDH1) D S Pheochromocytoma type 2 (SDHB) H D S Gastric carcer (MUC1) D S Pheochromocytoma type 3 (SDHC) D S Gastrointestinal stromal tumor (KIT) D S Pheochromocytoma type 4 (SDHD) D S Gastrointestinal stromal tumor, somatic (PDGFRA) D S Pheochromocytoma type 5 (SDHAF2) D S Glioma, BAI3 deficiency-related (BAI3) Page 8/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): Tumors & Solid Malignancies (continued)

D S Pheochromocytoma type 6 (VHL) D S Prostate cancer (STAG1) D S Pheochromocytoma type 8 (TMEM127) D S Renal cell carcinoma, papillary type 1 (MET) D S Pheochromocytoma type 9 (MAX) D S Renal chromophobe somatic carcinoma (FLCN) D S Pituitary adenoma, growth hormone secreting (GNAS) D S Retinoblastoma (RB1) D S Pituitary adenoma, growth hormone-secreting (AIP) D S RICTOR-related tumors (RICTOR) D S Pleuropulmonary blastoma (DICER1) D S RPTOR-related tumors (RPTOR) D S Polyposis syndrome, hereditary mixed (GREM1) D S carcinoma Hurthle cell (NDUFA13) D S Polyposis syndrome, hereditary mixed type 2 (BMPR1A) D S TJP1-related tumors (TJP1) D S Prostate cancer (PMEPA1) S D Tuberous sclerosis (TSC1) D S Prostate cancer (ELAC2) S D Tuberous sclerosis (TSC2) D S Prostate cancer (RNASEL) D S Tumor related CDK11A-deficiency (CDK11A) D S Prostate cancer (BRCA2) D S Tylosis with esophageal cancer (RHBDF2) D S Prostate cancer (SRD5A2) D S von Hippel-Lindau syndrome (VHL) D S Prostate cancer (ZNF783) D S Wilms tumor type 1 (WT1) Hematological Disorders & Malignancies

NGS Panels: D S Diamond-Blackfan anemia (RPL11, RPL35A, RPL5, RPS10, RPS17, RPS19, RPS24, RPS26, RPS7) D S panel (BRCA2, BRIP1, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCI, FANCL, FANCM, PALB2, SLX4, XRCC2) S Megaloblastic anemia panel (AMN, CUBN, GIF) S Spherocytosis panel (ANK1, EPB42, SLC4A1, SPTA1, SPTB) D S Thrombocytopenia panel (ADAMTS13, GATA1, GP1BA, GP1BB, GP9, ITGA2B, ITGB3, MASTL, MYH9, MPL, RUNX1, WAS) Single genes:

D S Afibrinogenemia, congenital (FGG) D S Factor II deficiency (F2) D S Afibrinogenemia, congenital (FGB) E Factor V deficiency (F5) D S Afibrinogenemia, congenital (FGA) D S Factor X deficiency (F10) D S Agammaglobulinemia, X-linked (BTK) D S Factor XI deficiency (F11) D S Alpha-2-macroglobulin deficiency (A2M) D S Factor XII deficiency (F12) D S Alpha-Thalassemia Myelodysplasia Syndrome, somatic (ATRX) D S Factor XIIIA deficiency H D S Anemia dyserythropoietic type 2 (CDAN1) H D S Fanconi anemia - XRCCR2 related (XRCC2) R S Anemia dyserythropoietic type 2 (SEC23B) H D S Fanconi anemia type A (FANCA) D S Anemia, neonatal hemolytic, fatal and near-fatal (SPTB) D S Fanconi anemia type B (FANCB) D S Anemia X linked (GATA1) H D S Fanconi anemia type C (FANCC) D S Aplastic anemia (TERC) D S Fanconi anemia type D1 (BRCA2) D S Aplastic anemia (TERT) H D S Fanconi anemia type D2 (FANCD2) D S Aplastic anemia (IFNG) D S Fanconi anemia type E (FANCE) D S Aplastic anemia (NBN) D S Fanconi anemia type F (FANCF) D S Aplastic anemia (PRF1) D S Fanconi anemia type G (FANCG) D S Aplastic anemia (SBDS) H D S Fanconi anemia type I (FANCI) D S Bone marrow failure (SRP72) H D S Fanconi anemia type J (BRIP1) D S Dehydrated hereditary stomatocytosis (PIEZO1) D S Fanconi anemia type L (FANCL) D S Diamond-Blackfan anemia type 1 (RPS19) D S Fanconi anemia type M (FANCM) D S Diamond-blackfan anemia type 3 (RPS24) H D S Fanconi anemia type N (PALB2) D S Diamond-Blackfan anemia type 4 (RPS17) D S Fanconi anemia type P (SLX4) D S Diamond-Blackfan anemia type 5 (RPL35A) D S Hemangioma capillary infantile (ANTXR1) D S Diamond-Blackfan anemia type 6 (RPL5) D S Hemochromatosis classical (HFE) D S Diamond-Blackfan anemia type 7 (RPL11) D S Hemochromatosis type 2A (HFE2) D S Diamond-Blackfan anemia type 8 (RPS7) D S Hemochromatosis type 2B (HAMP) D S Diamond-Blackfan anemia type 9 (RPS10) D S Hemochromatosis type 3 (TFR2) D S Diamond-Blackfan anemia type 10 (RPS26) D S Hemochromatosis type 4 (SLC40A1) D S Dyserythropoietic anemia (COX4I2) D S Hemophilia A (F8) D S Dyserythropoietic anemia, congenital type Ib (C15orf41) D S Hypereosinophilic syndrome, idiopathic, resistant to imatinib (PDGFRA) D S Dyserythropoietic anemia, congenital type 3 (KIF23) D S Intrinsic factor deficiency (GIF) D S Dyserythropoietic anemia, congenital type 4 (KLF1) D S Leukemia (PKHD1L1) D S Epstein syndrome (MYH9) DS Leukemia (M8D1) H D S Erythrocytosis, familial type 1 (SH2B3) D S Leukemia (MCM3AP) D S Erythrocytosis, familial type 3 (EGLN1) D S Leukemia (ZNF233) D S Erythrocytosis, familial type 4 (EPAS1) Page 9/10 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. RequisitionV3 Jan2015 GENETIC TESTING REQUISITION TUMORAL & HEMATOLOGICAL DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): Hematological Disorders & Malignancies (continued)

D S Leukemia, acute lymphoblastic (BRC) D S Myeloproliferative disorder, chronic, with eosinophilia (PDGFRB) D S Leukemia, acute lymphoblastic (FLT3) D S Neutropenia, severe congenital type 1 (ELANE) D S Leukemia megakaryoblastic of Down syndrome (GATA1) D S Neutropenia, severe congenital type 3 (HAX1) D S Leukemia, acute myeloid (CEBPA) D S Neutrophilia, hereditary (CSF3R) D S Leukemia, acute myeloid (FLT3) D S Ovalocytosis (SLC4A1) D S Leukemia, acute myeloid (MLF1) D S Platelet aggregation disorder (PEAR1) D S Leukemia, acute myeloid (NPM1) D S Platelet dense granule secretion defect, excessive bleeding (FLI1) D S Leukemia, acute myeloid (NUP214) D S Platelet disorder with associated myeloid malignancy (RUNX1) H D S Leukemia, acute myeloid (PICALM) D S Shwachman-Diamond syndrome (SBDS) D S Leukemia, acute myeloid (RUNX1) D S Sickle cell anemia (HBB) D S Leukemia, acute nonlymphocytic (DEK) D S Spherocytosis type 1 (ANK1) D S Leukemia, acute promyelocytic (NUMA1) D S Spherocytosis type 2 (SPTB) D S Leukemia, acute promyelocytic (PML) D S Spherocytosis type 3 (SPTA1) D S Leukemia, atypical chonic (CSF3R) D S Spherocytosis type 5 (EPB42) D S Leukemia, chronic myeloid (BRC) D S Thalassemia, alpha (HBA1) D S Leukemia, lymphocytic (GGT5) D S Thalassemia, alpha (HBA2) D S Leukemia, Philadelphia -positive, resistant to imatinib (ABL1) D S Thalassemia, delta (HBD) D S Leukemia, ZNF521-related (ZNF521) D S Thalassemia, delta-beta (HBB) D S Leukemia/Lymphoma, B-cell type (t(14:18)) D S Thrombocytopenia type 2 (MASTL) D S Leukemia/Lymphoma, B-cell type (t(11:14)) D S Thrombocytopenia X linked (GATA1) D S Leukemia/Lymphoma, B-cell type (BCL3) D S Thrombocytopenia X linked intermittent (WAS) D S Lymphoma (BCL6) D S Thromocytopenia-Absent-Radius-Syndrome (RBM8A) D S Lymphoma, Burkitt (MYC) D S Thrombocytopenia congenital amegakaryocytic (MPL) D S Lymphoproliferative syndrome 1 (ITK) D S Thrombocytopenia, neonatal alloimmune (ITGA2B) D S Lymphoproliferative syndrome, X-linked type 1 (SH2D1A) D S Thrombocytopenia, neonatal alloimmune (ITGB3) D S Lymphoproliferative syndrome, X-linked type 2 (XIAP) D S Thrombocytopenia with beta thalassemia X-linked (GATA1) D S Lutheran inhibitor blood group (KLF1) D S Thrombosis, inflammation, autoimmune diseases (ENTPD1) D S Megaloblastic anemia type 1 (AMN) D S Thrombotic thrombocytopenic purpura (ADAMTS13) D S Megaloblastic anemia type 1 (CUBN) D S von Willebrand disease (VWF) D S Megaloblastic anemia syndrome, thiamine-responsive (SLC19A2) D S von Willebrand disease platelet type (GP1BA) H D S Myelodysplastic syndrome susceptibility (TET2) D S Wiedemann-Steiner syndrome (MLL)

Page 10/10 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. RequisitionV3 Jan2015