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GENETIC TESTING REQUISITION Please Ship All 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 1/5 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 October 2014 GENETIC TESTING REQUISITION CARDIOVASCULAR 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 gene, 10mL for panel) □ DNA (single gene:1-10ug, panel 10-100ug) □ *Filter card (1 card/30 exons: Available by request) □ Saliva (Oragene OG-510: Available by request) □ 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 ** Page 2/5 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 October 2014 GENETIC TESTING REQUISITION CARDIOVASCULAR 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), Sequencing (S), Repeat Expansion (R) and/or Deletion/Duplication (D) analysis Arrhythmias NGS Panels: (AKAP9,ANK2,CACNA1C,CACNB2,CASQ2,CAV3,DSC2,DSG2,DSP,GPD1L,JUP,KCNA5,KCNE1,KCNE2,KCNE3,KCNH2,KCNJ2,KCNQ1, D S Arrhythmia, hereditary panel NPPA,PKP2,PLN,RYR2,SCN1B,SCN3B,SCN4B,SCN5A,SNTA1,TGFB3,TMEM43) D S Brugada syndrome panel (CACNA1C, CACNB2, GPD1L, HCN4, KCNE3, SCN1B,SCN3B, SCN5A, SLMAP) Catecholaminergic polymorphic (RYR2, CASQ2, KCNJ2) D S ventricular tachycardia panel D S Long QT syndrome panel (AKAP9, ANK2, CACNA1C, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNJ5, KCNQ1, SCN4B, SCN5A, SNTA1) Single genes: H D S Atrial fibrillation type 3 (KCNQ1) H D S Long QT syndrome type 1 (KCNQ1) D S Atrial fibrillation type 4 (KCNE2) D S Long QT syndrome type 2 (KCNH2) D S Atrial fibrillation type 6 (NPPA) H D S Long QT syndrome type 3 (SCN5A) D S Atrial fibrillation type 7 (KCNA5) D S Long QT syndrome type 4 (ANK2) H D S Atrial fibrillation type 10 (SCN5A) E D S Long QT syndrome type 5 (KCNE1) D S Atrial fibrillation type 11 (GJA5) D S Long QT syndrome type 6 (KCNE2) H D S Brugada syndrome type 1 (SCN5A) D S Long QT syndrome type 8 (CACNA1C) D S Brugada syndrome type 2 (GPD1L) H D S Long QT syndrome type 9 (CAV3) D S Brugada syndrome type 3 (CACNA1C) D S Long QT syndrome type 10 (SCN4B) D S Brugada syndrome type 4 (CACNB2) D S Long QT syndrome type 11 (AKAP9) D S Brugada syndrome type 5 (SCN1B) D S Long QT syndrome type 12 (SNTA1) D S Brugada syndrome type 6 (KCNE3) D S Long QT syndrome type 13 (KCNJ5) D S Brugada syndrome type 7 (SCN3B) D S Progressive familial heart block (TRPM4) D S Brugada syndrome type 8 (HCN4) D S Short QT syndrome type 1 (KCNH2) H D S Brugada syndrome type 9 (SLMAP) H D S Short QT syndrome type 2 (KCNQ1) H D S Catecholaminergic polymorphic Ventricular tachycardia type 1 (RYR2) D S Short QT syndrome type 3 (KCNJ2) H D S Catecholaminergic polymorphic Ventricular tachycardia type 2 (CASQ2) H D S Sick sinus syndrome type 1 (SCN5A) D S Catecholaminergic polymorphic Ventricular tachycardia type 3 (CALM2) H D S Sick sinus syndrome type 3 (MYH6) D S Catecholaminergic polymorphic Ventricular tachycardia type 4 (CALM1) H D S Sudden infant death syndrome (SCN5A) H D S Heart block type 1 (SCN5A) H D S Ventricular fibrillation, paroxysmal familial type 1 (SCN5A) H D S Jervell and Lange-Nielsen syndrome type 1 (KCNQ1) D S Ventricular tachycardia, familial (GNAI2) E D S Jervell and Lange-Nielsen syndrome type 2 (KCNE1) D S Wolff -Parkinson-White syndrome (PRKAG2) Cardiomyopathies NGS Panels: Arrhythmogenic right ventricular (DSP, DSG2, DSC2, JUP, PKP2, RYR2, TMEM43) D S cardiomyopathy panel Cardiomyopathy dilated panel (ABCC9, ACTC1, ACTN2, BAG3, CSRP3, DES, DMD, DSG2, EYA4, FKTN, GATAD1, LAMP2, LDB3, LMNA, MYBPC3, MYH6, MYH7, MT- D S ND1, MT-ND5, MT-ND6, MT-TD, MT-TH, MT-TI, MT-TK, MT-TL1, MT-TL2, MT-TM, MT-TQ, MT-TS1, MT-TS2, NEXN, PLN, PSEN1, PSEN2, RBM20, SCN5A, SDHA, SGCD, TAZ, TCAP, TMPO, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL) (ACTC1, CALR3, CAV3, CSRP3, GLA, JPH2, LAMP2, MYBPC3, MYH6, MYH7, MYL2, MYL3, MYLK2, MYOZ2, NEXN, PLN, PRKAG2, D S Cardiomyopathy hypertrophic panel SLC25A4, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL) Single genes: D S Arrhythmogenic right ventricular cardiomyopathy type 1 (TGFB3) D S Cardiomyopathy, dilated
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