DIAGMOL Town, ZIPCODE :…………………………………………………… Director : Prof

Mr.  Mrs.  (IN UPPER CASE, please) Name:…………………………………………………….

Maiden Name:……………………………………. DMGL / Service de Médecine Génétique Centre d’accueil des prélèvements (CAP) First name :………………………………………………… Bâtiment des Laboratoires (BATLab), local 8D-0-850.1 Date of birth : ...... / ...... / …………… 4 rue Gabrielle-Perret-Gentil, 1211 Genève 14 Legal representative (for minors) : father mother Molecular and Genomic Diagnostics Laboratory Name/first name :…………………………………………… Street/N°:……………………………………………………… http://www.hug-ge.ch/feuilles-de-demande DIAGMOL Town, ZIPCODE :…………………………………………………… Director : Prof. Stylianos ANTONARAKIS Hospitalisation Unit: …………… Physician :…………………… Lab managers: N° EdS : …………………………………………………………… Dr J.-L. BLOUIN, Dr Th. NOUSPIKEL, Dr. M. GUIPPONI Invoice address: Patient Prescriptor Insurance [email protected], [email protected], [email protected] Type of case : Disease AI Accident Pregnancy

Lab direct or results: Phone/FAX: +41 (0) 22 37 21 826 / 21 860 N° AVS (Mandatory for AI) : ………………………......

Sample Entrance Center (CAP) : Phone +41 (0) 22 37 21 800 Insurance : ………………… Insured N° : ………………………

PHYSICIAN PHYSICIAN (NAME/First name - Street/N°- Town, ZIPCODE - Phone/FAX. IN UPPER CASES, PLEASE)

COPY TO OTHER PHYSICIAN (NAME/First name - Street/N°- Town, ZIPCODE - Phone/FAX. IN UPPER CASES, PLEASE)

« The laboratory is granted permission by the Physician/Patient to transmit copies of the report to other physicians»  Opposition of the patient to the registration of this request results in the electronic patient record (DPI) of the HUG

If the patient belongs to a family already known to the laboratory, please indicate index case NAME:

CLINICAL INFORMATIONS given by the physician:

Ethnic origins Father Mother

Currently pregnant Date of last menses Number of weeks of amenorrhea

SAMPLE(S) Most of our tests work from 4 ml of blood in EDTA (children <2 ans : 1 On every and single NAME First name ml : ok) or from purified DNA (some exceptions apply for some tests) tube. Mandatory ! Date of birth Please contact us for any other type of sample. EDTA

Sampling date : Time (optional) : Sample Number :

 Blood Prenatal Réservé au laboratoire

 Amniotic fluid Tissu O sang/EDTA O ADN O ADN déjà en banque  Other Please indicate type :  Chorionic villi O Liq. Amnio. O CVS O Tissus fixés

Ο Biopsie O Salive Ο autre :  DNA from external source Fetal tissue

Reference : Quantité, Remarques : Other  DNA already in bank at our laboratory Reference number: (if known) TEST LIST : SEE OVER (PAGES 3 ET 4)

 Report in English (default: in French)

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NAME, First name : Laboratory only (CAPITAL LETTERS, please) DM-

PHYSICIAN’S SIGNATURE AND INFORMED CONSENT PHYSICIAN (NAME/First name – Street/N°- Town, ZIPCODE - Phone/FAX) : * By signing here, the physician confirms having informed the patient/the legal representative Date and Physician’s signature MANDATORY* according to the current legal requirements (LAGH in Switzerland, http://www.sgmg.ch) (including on the cost of tests that are not covered by health insurances), that the patient/ the legal representative had enough time to ask questions and take his/her decision, and having received the patient’s/the legal representative’s informed consent.

The patient has given his informed consent for the checked analyses that are listed at the pages 3-4, to be done on the sample specified at the first page.

The following questions marked by a star * must be checked (MANDATORY !).

Decision of the patient regarding the storage and use of his/her remaining biological sample(s) and data : *mandatory

 He/she agrees that the remaining biological material and data will be stored for possible further analyses. His/her informed consent will be necessary for any further additional analyses. * YES NO In case of a negative answer the remaining biological sample will be destroyed after the analysis.

 He/she agrees that his/her biological sample and data are used anonymously for quality testing. * YES NO

* MANDATORY ONLY FOR ANALYSES INVOLVING HIGH THROUGHPUT SEQUENCING OF WHOLE EXOME (SEE PAGE 4)

Decision of the patient regarding the transmission of results not directly related to the testing requested (so called “incidental findings”) *mandatory He/she wishes to be informed about genetic results belonging to the following categories :

 Carrier of a disorder for which preventive and/or therapeutic measures are available* : YES NO

Person incapable of discernment: YES NO

The following questions do NOT apply for persons incapable of discernment  Carrier of a disorder for which no preventive / therapeutic measures are yet available* : YES NO

 Healthy carrier of a recessive disorder which could concern the following generation or other family members* : YES NO

 Other decisions : ______

OPTIONAL

The use of his/her sample and data for research purposes. Should he/she agree in principle to participate in research studies you could indicate this below. Should this be the case he/she would be contacted at a later stage with details concerning the research projects. A positive answer below is not yet consent for the participation in any actual research projects.  In principle, he/she agrees that his/her biological sample and data could be used for research purposes YES NO

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NAME, First name : Laboratory only (CAPITAL LETTERS, please) DM-

REQUESTED ANALYSIS / ANALYSES NB: IF REQUEST IS FOR A HIGH THROUGHPUT SEQUENCING (GENOME CLINIC), PLEASE GO DIRECTLY TO PAGE 4. !! Test not included in the Swiss federal list of laboratory tests (OFSP, BAG, FOPH). The out-of-list tests are not automatically reimbursed by Swiss health insurances. § Test not accredited; @ Please contact us in advance. All prices are in Swiss Franc (CHF), not including DNA extraction cost (see DNA banking). For prenatal tests (urgent), an additional charge applies (200 CHF). The laboratory reserves the right to select the most appropriate technique (traditional or high throughput sequencing, cf. page 4) based on efficiency and cost effectiveness.

General tests  HIDS, MVK gene 530 CHF  Amyloidosis (familial, TTR) 960 CHF  MPZ gene sequencing (CMT1B) 1390 CHF  TRAPS, TNFRSF1A gene 530 CHF  GJB1 gene sequencing (CMTX) 745 CHF HNPP (tomaculous neuropathy)  AS, Angelman syndrome 533 CHF Chromosomal Microdeletions !! §  Deletion CMT1A 450 CHF  HED, Hypohidrotic Ectodermal Dysplasia (EDA) 1605-  22q11, MLPA 470 CHF  PMP22 gene sequencing 960 CHF 1955 CHF  Screening, sub-telomeric, MLPA 450 CHF Lynch syndrome (HNPCC)  APECED (AIRE) 1605 CHF  Screening, recurrent microdeletions, MLPA 450 CHF  Full screening MLH1+MSH2+MSH6+PMS2 (2900-  Beckwith-Wiedemann syndrome (BWS) 533 CHF 4165 CHF) § or  BPES Bleph. Pto. Epicanth. (FOXL2) !! 530-880 CHF Cystic Fibrosis (CF, CFTR)  MLH1+PMS2 genes 2900-3600 CHF § CFTR: please indicate the ethnic origins of the patient  MSH2+MSH6 genes 2900-3600 §  CMM2 Cutan. Malign. Melanoma (CDKN2A) !! at page 1  MSI (on tumor biopsy) 185 CHF 745-1095 CHF  Screening frequent mutations (+IVS8 5T,  BRAF1 V600E (on tumor biopsy) 315 CHF §  FG (Keller syndrome, MED12) !! § 530 CHF CFTR-related disorders) 450 CHF Male infertility  HBLRG, Gilbert syndrome (UGT1A1) !! 285 CHF  Full CFTR analysis (sequencing+ del/dup by  CFTR+5T (frequent mutations) 470 CHF  HDGC, Hered. Diff. Gastric Cancer (CDH1) 215 CHF MLPA) § 1820-2170 CHF  Y chromosome microdeletions (DAZ) 415 CHF  Hyperechogenic fetal bowel Mitochondriopathies (ADNmt)  HFE-HH, Hered. Hemochromatosis (HFE) !! 286 CHF (frequent mutations CFTR in parents) 470 CHF  MELAS, MERRF, NARP Screening 472 CHF  HSCR, Hirschsprung (RET) !! § 2740 CHF  Hyperechogenic fetal bowel  Deletions/Dup (muscle biopsy only ) !! 556 CHF  XLI, Ichtyosis, X-linked type (STS) § 450 CHF (frequent mutations CFTR +del/dup by MLPA in Monogenic Diabetes (MODY, NDM) §  IP, Incontinentia pigmenti (IKBKG) !! § 1955 CHF parents) 820 CHF  Targeted Exome Sequencing (gene panel) 2900- Deafness 3515 CHF  PFIC3, Intrahepatic Cholestasis (ABCB4) !! § 2680 CHF  DFNB1, congenital (CX26 et CX30) !! 665 CHF  HNF4A gene (MODY 1) 1605-1955 CHF  SMAX1, Kennedy (SBMA, AR) § 285 CHF  Mitochondrial mutations !! § 645 CHF  GCK gene (MODY 2) 1605-1955 CHF  KNO1, Knobloch, (COL18A1) § 1390 CHF Endocrine Neoplasias, Pheochromocytoma,  HNF1A gene (MODY 3) 1605-1955 CHF  Lactose intolerance (LCT) !! 188 CHF Paraganglioma (MEN, PCC, PGL)  PDX1 gene (MODY 4) 530-880 CHF  PGL/PCC, Paraganglioma/Pheochromocytoma:  HNF1B gene (MODY 5) 1605-1955 CHF  LHON, Leber optical neuropathy 474 CHF Full sequencing (+MLPA) 2900 CHF (3950 CHF) or  INS gene (MODY 10) 530-880 CHF  LWD, Leri-Weill (SHOX) 450 CHF  MEN1, Multi. Endoc. Neopl. type I (MEN1) 1605-  KCNJ11 gene 530-880 CHF  LFS, Li Fraumeni, (TP53) 1605-1955 CHF 1955 CHF Neurological and Neuromuscular  NF1, Neurofibromatosis type I (NF1) § 3890 CHF  MEN2, Multi. Endoc. Neopl. type II (RET) 1605 CHF  SMA, Spinal Musc. Amyotrophy (SMN1) 450 CHF  VHL, Von Hippel Lindau (VHL) 745-1095 CHF  CADASIL (NOTCH3) !! 1605 CHF  PJS, Peutz-Jeghers (STK11) !! §1605-1955 CHF  SDHB gene 1955 CHF  DOPA-responsive dystonia (GCH1) !! §1740 CHF  PTEN Hamartoma Tumor syndrome (PHTS, Cowden,  SDHC gene § 1650 CHF  Dravet syndrome (SCN1A) !! § 1605-1955 CHF Hamartomas, BRRS, Proteus, PTEN) !! 1605-1955 CHF  SDHD gene 1310 CHF  EPM1, Unverricht-Lundborg (CSTB) !!  PWS, Prader-Willi 533 CHF Familial Pneumothorax (Birt-Hogg-Dubé, BHD) !! § Southern+sequencing 1108 CHF  RETT syndrome (MECP2) 1310 CHF  Frequent mutation, FLCN, exon 11 315 CHF  FSHD, Facio-Scapulo-Humeral Dystrophy  FLCN full gene analysis 2680-2930 CHF (only from EDTA blood), 660 CHF  RSS, Russell-Silver syndrome (11p15) 533 CHF Familial Adenomatous Polyposis (FAP) §  GLUT1 (SLC2A1) !! §1955 CHF HBB 288 CHF  Sickle cell anemia (Drepanocytosis, )  Full Screening APC+MUTYH § (2900-3600 CHF) or  SPAST, Hered. Spastic Paraparesis (SPG4) 450  UPD, Uniparental Disomy, Chr :______285 CHF  APC gene 2895-3245 CHF CHF  VWF type 2N (Normandy) 1075 CHF  MAP (MUTYH, ex. 7,13) 530 CHF  STARTLE (Hyperekplexia (GLRA1) § 1605 CHF FGFR3 (syndromes linked to)  DMD, BMD, Muscular Dystroph Duchenne/Becker  VWF Types 2B, 2M (exon 28) § 960 CHF  Achondroplasia 315 CHF (DMD), deletions !! § 800 CHF VWF, other types, please contact us § @   Hypochondroplasia § 745 CHF  DM1, Myotonic Dystrophy of Steinert (DMPK) 285-  WAGR, Wilms tumor (WT1) § 533 CHF  TD types I, II § 960 CHF 670 CHF Alpha-1-antitrypsin deficiency (A1AT)  Muenke § 315 CHF  OPMD, Oculopharyngeal Muscular Dystrophy  Genotyping PI*S/Z 310 CHF  SADDAN § 315 CHF (PABPN1) !! § 315 CHF  Full sequencing of SERPINA1 § 960 CHF Fibrinopathies !!  PD, Parkinson (PARK1 & 2, LRRK2) !! § 800 CHF Ashkenazi mutations (rare disease carrier) !!  Afibrinogenemia (FGA, FGB, FGG) 1710 CHF  TOR1A, Torsion Dystonia (DYT1) !! § 315 CHF  Full screening (950 CHF) or  Dysfibrinogenemia (FGA, FGB, FGG) 1710 CHF Pancreatitis  CFTR  Gaucher  Fragile-X  Hypofibrinogenemia (FGA, FGB, FGG) 1710 CHF  CFTR+ IVS8 5T (33 mutations) 450 CHF  Tay-Sachs+ FD+Fanconi+Canavan Fragile X (FRAXA, FMR1) §  SPINK frequent mutation 215 CHF  von Gierke+Bloom+Niemann-Pick+ML-IV  Diagnostic 285 CHF  PRSS1 frequent mutations !! 530 CHF Individual prices available upon request  Carrier testing 285 CHF Primary Ciliary Dyskinesia (PCD) !! § Ataxias  Premature ovarian failure (POI) 285 CHF  Whole Exome Sequencing and Targeted Gene  Full screening (1765 CHF) or 185 CHF per gene Genetic sex!! § Panel Analysis: see next page (page 3) +100 CHF  Genetic sex determination 210 CHF  DNAI1 + DNAH5 targeted screening (2150 CHF) or  SCA1 §  SCA2 §  SCA3 §  SRY search in a Turner 285 CHF  DNAI1 gene 960 CHF  SCA6 §  SCA7 §  SCA17 §  SRY sequencing 530 CHF  DNAH5 gene 1605 CHF  Friedreich  DRPLA §  FMR1 § Hemophilias Waardenburg (WS) !! Cardiac Arrhythmias (Channelopathies, CCP) !! §  HA, inversions F8 (IVS22, IVS1) 530 CHF  Types I and III (PAX3 gene) 1605-1955 CHF  SCN5A gene (Brugada) 2680 CHF  HA, F8, complete analysis 1605-1955 CHF §  Type II (MITF gene) § 1605-1955 CHF  KCNQ1 gene (QT-long) 2680 CHF  HB, F9, complete analysis 1605-1955 CHF  KCNH2 gene (QT-long) 2680 CHF Huntington disease (HD, HTT) 285 CHF Miscelleanous (cf. additional informations)  KCNE1, KCNE2, KCNJ2 genes 1605 CHF  Diagnostic  DNA Extraction + Banking 61 CHF  Whole Exome Sequencing and Targeted Gene  Presymptomatic (2 tubes please)  Out-of-list (OFAS) gene (§,!!) per exon 215 CHF, max Panel Analysis : see next page (page 3) Hereditary Periodic Fevers (HRF) !! 2900-3250 CHF Cardiomyopathies (HCM, DCM, NC, CMR,…) !! §  Full Sequencing (4 genes) 2900 CHF  Specific/ Known familial mutation (§,!!) 315 CHF  Whole Exome Sequencing and Targeted Gene  Full Screening Frequent Mutations (4 genes)  Exclusion of maternal contamination in fetal Panel Analysis: see next page (page 3) 1820 CHF sample (amnio-, choriocentesis) !! 185 CHF Charcot-Marie-Tooth (CMT)  FMF, MEFV gene 530 CHF  Duplication CMT1A 450 CHF  FMF, MEFV gene (complete sequencing) 1605 CHF  PMP22 gene sequencing (CMT1A) 960 CHF  CAPS, NLRP3 gene 530 CHF

Please indicate here any additional helpful information, other specific tests, desired order of analyses (for multiple tests)….

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NAME, First name : Laboratory only (CAPITAL LETTERS, please) DM-

REQUESTED ANALYSIS / ANALYSES GENOME CLINIC : HIGH THROUGHPUT SEQUENCING OF TARGETED OR WHOLE EXOME AND BIOINFORMATIC ANALYSIS !! Test not included in the Swiss federal list of laboratory tests (OFSP, BAG, FOPH). The out-of-list tests are not automatically reimbursed by Swiss health insurances. § Test not accredited; @ Please contact us in advance. All prices are in Swiss Franc (CHF), not including DNA extraction cost (see DNA banking). For prenatal tests (urgent), an additional charge applies (200 CHF). The laboratory reserves the right to select the most appropriate technique (high throughput sequencing or traditional, cf. page 3) based on efficiency and cost effectiveness.

 DNA extraction and banking 61 CHF  High throughput sequencing (HTS) et bioinformatic analysis High throughput sequencing: 2300 CHF. Bioinformatic analysis 1-10 genes: 600 CHF; 11-100 genes: 1000 CHF ; more than 100 genes : 1500 CHF  Additional bioinformatic analysis (in case of further analysis of HTS data): 1-10 genes: 600 CHF; 11-100 genes : 1000 CHF ; more than 100 genes : 1500 CHF  Additional analyses  Sanger 215 CHF  MLPA 350 CHF  Other : ______

 Comment:______

High throughput sequencing followed by bioinformatic analysis of 1 to 10 genes (2900 CHF) Prescription by a physician with a federal postgraduate FMH diploma in medical genetics or related to the examined pathology, accordingly to the List des analyses of the Swiss federal health insurance.  Cardiac Channelopathies (CCP) !! §  Neurofibromatosis type I §  Cardiomyopathies !! §  Growth disorder syndromes §  Primary Ciliary Dyskinesia (PCD) !! § (Beckwith-Wiedemann, Silver-Russel, Sotos, etc)  FGF receptor-associated dysplasias § Other orphan diseases (please specify below the genes to analyze) Duchenne et Becker dystrophinopathies §   An “Orphan disease” reimbursement request must be done by a physician  Hereditary periodic fever !! § with a federal postgraduate FMH diploma  Wilson’s disease §

High throughput sequencing followed by a bioinformatic analysis of more than 10 genes (3300 CHF – 3800 CHF) Prescription only by a physician with a federal postgraduate FMH diploma in medical genetics, accordingly to the List des analyses of the Swiss federal health insurance.

Cardiac Channelopathies (CCP) !! § Metabolic and endocrine diseases §  11-100 genes 3300 CHF  11-100 genes 3300 CHF Cardiomyopathies !! §  > 100 genes 3800 CHF  11-100 genes 3300 CHF Diseases related to urogenital system, fertility / sterility § Primary Ciliary Dyskinesia (PCD) (PCD) !! §  11-100 genes 3300 CHF  11-100 genes 3300 CHF  > 100 genes 3800 CHF Muscular dystrophies § Sensorimotor neuropathies § (due to non- or dysfunctional dystrophin-related proteins) (CMT, HNPP, amyloid polyneuropathy)  11-100 genes 3300 CHF  11-100 genes 3300 CHF Ehlers-Danlos § Kallman syndrome §  11-100 genes 3300 CHF  11-100 gènes 3300 CHF Diseases related to coagulation, blood and immune system disorders§ Marfan syndrome and other thoracic aorta syndroms §  11-100 genes 3300 CHF  11-100 genes 3300 CHF  > 100 genes 3800 CHF Mendelian syndrome with growth disorder § Neuromuscular et neurodegenerative diseases §  11-100 genes 3300 CHF  11-100 genes 3300 CHF  > 100 genes 3800 CHF  > 100 genes 3800 CHF Diseases related to skin, connective tissue and bone disorders § Other orphan diseases (please specify below the genes to analyze)  11-100 genes 3300 CHF An “Orphan disease” reimbursement request must be done by a physician with a federal postgraduate FMH diploma  > 100 genes 3800 CHF  11-100 genes 3300 CHF

 > 100 genes 3800 CHF SEARCH FOR VARIANTS IN THE PARENTS In case of request of search of variants in the parents, please send us for each of them the sample and a request of DNA extraction and banking.

 Please verify readily in the parents the variants identified in the index patient  Consanguineous parents  Comments:______

INFORMATIONS RELATED TO BIOINFORMATIC ANALYSES Gene panel to analyze (please contact us in advance) :  Development delay disorders  Epilepsy

 Personalized gene panel :______(Please specify the investigated pathology, the number of genes as well as the requested gene panel – and please provide your gene list in an Excel file)

Please indicate here any complementary and useful information(s), other specific analyses, specific order to follow when several different analyses are requested, etc.

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