UNIVERSITY OF MINNESOTA PHYSICIANS OUTREACH LABS Submit this form along with the appropriate Molecular requisition (Molecular Diagnostics or MOLECULAR DIAGNOSTICS (612) 273-8445 Molecular NGS Oncology). DATE: TIME COLLECTED: PCU/CLINIC: AM PM PATIENT IDENTIFICATION DIAGNOSIS (Dx) / DIAGNOSIS CODES (ICD-9) - OUTPATIENTS ONLY SPECIMEN TYPE: o Blood (1) (2) (3) (4) PLEASE COLLECT 5-10CC IN ACD-A OR EDTA TUBE ORDERING PHYSICIAN NAME AND PHONE NUMBER: Tests can be ordered as a full panel, or by individual gene(s). Please contact the genetic counselor with any questions at 612-624-8948 or by pager at 612-899-3291. ______Test Ordered- EPIC: Next generation sequencing(Next Gen) Sunquest: NGS Nijmegen Breakage syndrome Full panel Adrenoleukodystrophy DNA breakage NBN ABCD1 RAD50 Bone marrow failure, familial syndromes OMENN Syndrome SRP72 Bloom syndrome Full panel Diamond Blackfan Anemia BLM DCLRE1C Full panel Cockayne syndrome RAG1 RPS19 Full panel RAG2 RPS26 ERCC8 Roberts Syndrome RPS24 ERCC6 ESCO2 RPS17 DNA ligase deficiency Rothmund-Thomson syndrome RPL35A Full panel RECQL4 RPL5 LIG1 Schwachman Diamond syndrome RPL11 LIG3 SBDS RPS7 LIG4 Severe combined immunodeficiency RPS10 Dyskeratosis congenita with microcephaly, growth RPL36 Full panel retardation, and sensitivity to ionizing RPS15 TERC radiation RPS27A TINF2 NHEJ1 Seckel syndrome Hemophagocytic NOP10 ATR lymphohistiocytosis NHP2 WRAP53 Warsaw Breakage Syndrome Full panel TERT DDX11 PRF1 DKC1 Werner syndrome UNC13D Fanconi anemia WRN STX11 Xeroderma Pigmentosum STXBP2 Full panel Full panel ERCC1 Metachromatic leukodystrophy FANCA FANCB XPA ARSA FANCC ERCC3 Osteopetrosis BRCA2 XPC ERCC2 Full panel FANCD2 DDB2 CLCN7 FANCE FANCF ERCC4 TCIRG1 FANCG ERCC5 TNFSF11 FANCI POLH CA2 BRIP1 Ectodermal dysplasia/skin fragility OSTM1 FANCL syndrome PKP1 PLEKHM1 FANCM PALB2 TNFRSF11A RAD51C SNX10 SLX4 ERCC4 4/1/2014 Version 1 Epidermolysis bullosa Epidermolysis bullosa dystrophica COL7A1 Epidermolysis bullosa simplex KRT14 KRT5 Muscular dystrophy with epidermolysis bullosa simplex PLEC Epidermolysis bullosa, junctional Full panel LAMA3 LAMB3 LAMC2 COL17A1 ITGB4 ITGA6 Epidermolysis bullosa, lethal acantholytic DSP
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