Nobarcodes Biochemmolecular
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General Test Requisition Form Please complete every field and tick box clearly. BioChemical and Molecular PATIENT INFORMATION Patient’s First Name Patient’s Last Name MM/ DD/ YY Patient’s Street Address Patient’s Date of Birth Patient’s Email City / Town State Zip Code Country Patient’s Preferred Phone Ethnicity (check all that apply): African-AmericanAsian (China, Japan, Korea) Caucasian/N.European/S.European Biological Sex: Finnish French Canadian Hispanic Jewish- Ashkenazi Jewish- Sephardic Male Female Mediterranean Middle Eastern (Saudi Arabia, Qatar, Iraq, Turkey) Native American E. Indian Unknown Ambiguous Southeast Asian (Vietnam, Cambodia, Thailand) South Asian (India, Pakistan) Other (specify) PROVIDER INFORMATION REQUESTING PROVIDER Provider’s First Name Provider’s Last Name Clinic / Hospital / Institution Name Provider’s Phone Provider’s NPI Reporting Street Address Provider’s Email City / Town State Zip Code Country Provider’s Fax SEND ADDITIONAL REPORTS TO: GENETIC COUNSELORADDITIONAL PROVIDER NA GENETIC COUNSELOR (IF APPLICABLE) Genetic Counselor’s Name Genetic Counselor’s Email Genetic Counselor’s Phone Genetic Counselor’s Fax ADDITIONAL PROVIDER CONTACT Additional Provider’s Name Additional Provider’s Email Additional Provider’s Phone Additional Provider’s Fax SPECIMEN INFORMATION AM SAMPLE TYPE: Whole Blood (Biochemical and Molecular) Other MM/ DD/ YY : PM Date of Sample Collection Time of Sample Collection Dried Blood Spots (Biochemical and Molecular) Saliva (Molecular only) 1 BILLING INFORMATION INSTITUTIONAL BILLING Institution / Organization Contact Name Institution Phone Institutional Billing Street Address Institution Email City / Town State Zip Code Institution Fax SELF PAY Please make checks payable to: PerkinElmer Genetics, Inc. Cashier Check $ Amount Enclosed Credit Card (Please fill out all information): CVV Credit Card Number MM/ YY Cardholder Billing Street Address Card Exp. Date Cardholder Phone City / Town State Zip Code Cardholder Printed Name as Appears on Card Cardholder Signature 2 PANEL TESTS METABOLIC ANALYTES AND PROFILES - BIOCHEMICAL TEST CODE DESCRIPTION SPECIMEN AC ACYLCARNITINE PROFILE DBS, WB AA AMINO ACID PROFILE DBS, WB OA ORGANIC ACID PROFILE DBS, WB GAL GALACTOSEMIA - GALACTOSE-1-PHOSPHATE URIDYLTRANSFERASE ENZYME ANALYSIS AND TOTAL GALACTOSE. DBS, WB LSD ENZYME PANEL: FABRY DISEASE, GAUCHER DISEASE, KRABBE DISEASE, MAROTEAUX-LAMY SYNDROME (MPS VI) LSDALL DBS, WB MORQUIO A SYNDROME (MPS IVA), HURLER SYNDROME (MPS I), NIEMANN PICK DISEASE TYPE A/B, POMPE DISEASE HGB SICKLE CELL & OTHER HEMOGLOBINOPATHIES: ISOELECTRIC FOCUSING GEL ELECTROPHORESIS OF HEMOGLOBINS DBS, WB STEPONE® BIOCHEMICAL PROFILE - INCLUDES: 17OHP, AA, AC, BIO, IRT, GAL, HGB, TSH, GLA, ABG, GALC, IDUA, ASM, GAA, XALD, StepOne DBS, WB SCID, G6DNA METABOLIC / NBS DISORDERS - MOLECULAR LSDS LYSOSOMAL STORAGE DISORDER (LSD) GENE SEQUENCING PANEL (12 GENES) DBS, WB, SV NBSS NEWBORN SCREENING (NBS) GENE SEQUENCING PANEL (82 GENES) DBS, WB, SV NBSLSDS NBS AND LSD GENE SEQUENCING PANEL (94 GENES) DBS, WB, SV SCIDS SEVERE COMBINED IMMUNODEFICIENCY (SCID) GENE SEQUENCING PANEL (26 GENES) DBS, WB, SV MCCS 3-METHYLCRONTONYL-COA-CARBOXYLASE DEFICIENCY: MCCC1, MCCC2 GENE SEQUENCING DBS, WB, SV BIOPRECS BIOPTERIN DEFECT IN COFACTOR RECYCLING: PCBD1, QDPR GENE SEQUENCING DBS, WB, SV BIOPSYNS BIOPTERIN DEFECT IN COFACTOR SYNTHESIS: GCH1, PTS GENE SEQUENCING DBS, WB, SV MMAS COBALAMIN A / B DEFICIENCY: MMAA, MMAB GENE SEQUENCING DBS, WB, SV GA2S GLUTARIC ACIDEMIA TYPE II: ETFA, ETFB, ETFDH GENE SEQUENCING DBS, WB, SV LCHADS LONG-CHAIN 3-HYDROXYACYL-COA DEHYDROGENASE DEFICIENCY: HADHA, HADHB GENE SEQUENCING DBS, WB, SV MSUDS MAPLE SYRUP URINE DISEASE: BCKDHA, BCKDHB, DBT GENE SEQUENCING DBS, WB, SV PCCS PROPIONIC ACIDEMIA: PCCA, PCCB GENE SEQUENCING DBS, WB, SV NEWBORN AND PEDIATRIC GENE PANELS NBSS NEWBORN SCREENING (NBS) GENE SEQUENCING PANEL (82 GENES) DBS, WB, SV NBSLSDS NBS AND LSD GENE SEQUENCING PANEL (94 GENES) DBS, WB, SV NBSSEXP EXPANDED NEWBORN SCREENING (NBS) GENE SEQUENCING PANEL (275 GENES)* DBS, WB, SV NEOSEQ NEOSEQ NEWBORN AND PEDIATRIC GENE PANEL (1744 GENES)* DBS, WB, SV *Individual gene tests can be ordered from the panel. Please inquiry by calling the lab. INDIVIDUAL BIOCHEMICAL AND GENE TESTS METABOLIC / NBS DISORDERS - BIOCHEMICAL AC ACYLCARNITINE PROFILE DBS, WB AA AMINO ACID PROFILE DBS, WB OA ORGANIC ACID PROFILE DBS, WB BIO BIOTINIDASE DEFICIENCY (COMPLETE/PARTIAL) - BIOTINIDASE ENZYME ANALYSIS DBS, WB 17OHP CONGENITAL ADRENAL HYPERPLASIA - 17Α HYDROXYPROGESTERONE (17 OHP) DBS, WB TSH CONGENITAL HYPOTHYROIDISM - THYROID-STIMULATING HORMONE (TSH) DBS, WB T4 CONGENITAL HYPOTHYROIDISM - THYROXINE (T4) DBS, WB IRT CYSTIC FIBROSIS (NOT VALID AFTER 90 DAYS OF AGE) - IMMUNOREACTIVE TRYPSIN (IRT) DBS, WB DMDCK DUCHENNE MUSCULAR DYSTROPHY - CREATINE KINASE ENZYME ANALYSIS DBS, WB GLA FABRY DISEASE - ALPHA-GALACTOSIDASE A ENZYME ANALYSIS DBS, WB GAL GALACTOSEMIA - GALACTOSE-1-PHOSPHATE URIDYLTRANSFERASE ENZYME ANALYSIS AND TOTAL GALACTOSE. DBS, WB GALMON GALACTOSEMIA MONITORING - GALACTOSE-1-PHOSPHATE URIDYLTRANSFERASE ENZYME ANALYSIS AND TOTAL GALACTOSE. DBS, WB ABG GAUCHER DISEASE - GLUCOCEREBROSIDASE (GLUCOSYLCERAMIDASE) ENZYME ANALYSIS DBS, WB G6PD GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY DBS, WB GALC KRABBE DISEASE - GALACTOCEREBROSIDASE ENZYME ANALYSIS DBS, WB IDUA MPS I (HURLER SYNDROME) - ALPHA-L-IDURONIDASE ENZYME ANALYSIS DBS, WB IDS MPS II (HUNTER DISEASE) - IDURONATE 2-SULFATASE ENZYME ANALYSIS DBS, WB GALNS MPS IVA (MORQUIO A SYNDROME) - GALACTOSAMINE-6-SULFATASE ENZYME ANALYSIS DBS, WB MPS VI (MAROTEAUX-LAMY SYNDROME) - ARYLSULFATASE B ENZYME ANALYSIS ARSB MPS I (HURLER SYNDROME) - ALPHA-L-IDURONIDASE ENZYME ANALYSIS DBS, WB ASM NIEMANN PICK DISEASE TYPE A/B - ACID SPHINGOMYELINASE ENZYME ANALYSIS DBS, WB PKMON PKU MONITORING - PHENYLALANINE DBS, WB GAA POMPE DISEASE - ACID ALPHA-GLUCOSIDASE ENZYME ANALYSIS DBS, WB HGB SICKLE CELL & OTHER HEMOGLOBINOPATHIES - ISOELECTRIC FOCUSING GEL ELECTROPHORESIS OF HEMOGLOBINS DBS, WB SUACMO SUCCINYLACETONE (SUAC) DBS, WB TYRMON TYROSINEMIA MONITORING - SUCCINYLACETONE AND TYROSINE DBS, WB XALD X-LINKED ADRENOLEUKODYSTROPHY - C26:0 LYSOPHOSPHATIDYLCHOLINE DBS, WB POST MORTEM INCLUDES: 17-HYDROXY PROGESTERONE, ACYL CARNITINES, GALACTOSE, THYROID STIMULATING DBS, Vitreous POSTM Fluid, Bile, HORMONE Liver Tissue Blot 3 METABOLIC / NBS DISORDERS - MOLECULAR TEST CODE DESCRIPTION SPECIMEN XALDS ABCD1 XALD GENE SEQUENCING DBS, WB, SV ACAD8S ACAD8 ISOBUTYRYL-COA DEHYDROGENASE DEFICIENCY GENE SEQUENCING DBS, WB, SV MCADNA ACADM- MCADD MUTATION PANEL DBS, WB, SV MCADS ACADM-MCADD GENE SEQUENCING DBS, WB, SV SCADS ACADS SCADD GENE SEQUENCING DBS, WB, SV ACADSBS ACADSB 2-METHYLBUTYRYL GLYCINURIA GENE SEQUENCING DBS, WB, SV ACADVLS ACADVL VERY LONG CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY GENE SEQUENCING DBS, WB, SV ACAT1S ACAT1 BETA-KETOTHIOLASE DEFICIENCY GENE SEQUENCING DBS, WB, SV ADKS ADK HYPERMETHIONINEMIA GENE SEQUENCING DBS, WB, SV ARG1S ARG1 ARGININEMIA GENE SEQUENCING DBS, WB, SV ARSBS ARSB MPS VI (MAROTEAUX-LAMY SYNDROME) GENE SEQUENCING DBS, WB, SV ASLS ASL ARGININOSUCCINIC ACIDURIA GENE SEQUENCING DBS, WB, SV ASS1S ASS1 CITRULLINEMIA TYPE I GENE SEQUENCING DBS, WB, SV AUHS AUH 2-METHYLGLUTACONIC ACIDURIA GENE SEQUENCING DBS, WB, SV MSUDNA BCKDHA-MAPLE SYRUP URINE DISEASE MUTATION TESTING DBS, WB, SV MSUDS BCKDHA, BCKDHB, DBT MSUD GENE SEQUENCING DBS, WB, SV BIODNA BTD-BIOTINIDASE DEFICIENCY DBS, WB, SV BIOS BTD BIOTINIDASE GENE SEQUENCING DBS, WB, SV CBSS CBS HOMOCYSTINURIA GENE SEQUENCING DBS, WB, SV IRTEXT CFTR CYSTIC FIBROSIS MUTATION PANEL DBS, WB, SV CFTRS CFTR CYSTIC FIBROSIS GENE SEQUENCING DBS, WB, SV CPT1AS CPT1A CARNITINE PALMITOYL TRANSFERASE 1A DEFICIENCY GENE SEQUENCING DBS, WB, SV CPT2S CPT2 CARNITINE PALMITOYL TRANSFERASE II DEFICIENCY GENE SEQUENCING DBS, WB, SV 17OHPS CYP21A2 CAH GENE SEQUENCING AND DEL/DUP (MLPA) DBS, WB, SV DMD DMD DUCHENNE MUSCULAR DYSTROPHY DELETION/DUPLICATION DBS, WB, SV DMDS DMD DUCHENNE MUSCULAR DYSTROPHY GENE SEQUENCING DBS, WB, SV GA2S ETFA, ETFB, ETFDH GLUTARIC ACIDEMIA TYPE II GENE SEQUENCING DBS, WB, SV FAHS FAH TYROSINEMIA TYPE I GENE SEQUENCING DBS, WB, SV G6DNA G6PD GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY MUTATION PANEL DBS, WB, SV G6PDS G6PD GENE SEQUENCING DBS, WB, SV GAAS GAA POMPE DISEASE GENE SEQUENCING DBS, WB, SV GALES GALE GALACTOEPIMERASE DEFICIENCY GENE SEQUENCING DBS, WB, SV GALKS GALK GALACTOKINASE DEFICIENCY GENE SEQUENCING DBS, WB, SV GALNSS GALNS MPS IVA (MORQUIO SYNDROME A) GENE SEQUENCING DBS, WB, SV GALDNA GALACTOSEMIA MUTATION PANEL DBS, WB, SV GALTS GALT GALACTOSEMIA GENE SEQUENCING DBS, WB, SV GA1DNA GCDH-GLUTARIC ACIDEMIA TYPE I-MUTATION PANEL DBS, WB, SV GA1S GCDH GA1 GENE SEQUENCING DBS, WB, SV GALCS GALC KRABBE DISEASE GENE SEQUENCING DBS, WB, SV GBAS GBA GAUCHER DISEASE GENE SEQUENCING DBS, WB, SV GLAS GLA FABRY DISEASE GENE SEQUENCING DBS, WB, SV GLB1S GLB1 MPS IVB (GM1 GANGLIOSIDOSIS) GENE SEQUENCING DBS, WB, SV GUSBS GUSB MPS VII GENE SEQUENCING DBS, WB, SV HADHS HADH M/SCHADD GENE SEQUENCING DBS, WB, SV LCHADD HADHA- LONG CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY MUTATION ANALYSIS DBS, WB, SV LCHADS HADHA, HADHB LCHADD GENE SEQUENCING DBS, WB, SV HGBDNA SICKLE CELL & OTHER HEMOGLOBINOPATHIES MUTATION PANEL DBS, WB, SV HLCSS HLCS MULTIPLE CARBOXYLASE DEFICIENCY GENE SEQUENCING DBS, WB, SV HMGCLS HMGCL HMG-COA LYASE DEFICIENCY GENE SEQUENCING DBS, WB, SV HPDS HPD TYROSINEMIA TYPE III GENE SEQUENCING DBS, WB, SV IDUAS IDUA MPS I (HURLER SYNDROME) GENE SEQUENCING DBS, WB, SV