Molecular Diagnostic Laboratory 1600 Rockland Road, Wilmington, DE 19803 302.651.6775 email: [email protected] CLIA #08D0706140
Next Generation Sequencing (NGS) Panel Sample Submission
Patient Information Patient Name (Last, First): Biologic sex: Male Female Other or Unknown
Date of Birth (MM/DD/YYYY): Medical Record Number:
Collection date (MM/DD/YYYY): Sample Type: Blood DNA Buccal swab Other (Specify):
Ordering Physician (required) Additional report recipient (genetic counselor, send-out lab, etc.) Name: Name: Address: Address:
Phone: Fax: Phone: Fax: e-mail: e-mail: Billing Information (required) Please note: We do not bill third party payers (insurance companies). The person or Patient Bill Amount: $______institution sending the sample is responsible for full payment of the invoice. If paying by credit card, please complete additional information Please bill my credit card for the full amount stated above Signature of Card holder (required) Institutional Billing Include a billing contact at your institution, and an MasterCard Visa email to send the invoice. American Express Discover
Institution Name of Card holder
Contact name Credit Card Number
Email Fax: Phone: Expiration Date Security Code
Street Patient Billing Address:
City/State/Zip Code City/State/Zip Code Phone
Clinical Information- Clinical information is required for interpretation purposes; please attach additional clinic notes if appropriate. Brief description: Testing Requested Renal Disease Nephrotic syndrome and related disorders panel ACTN4; ALG1; ALMS1; APOL1; ARHGAP24; ARHGDIA; CD151; CD2AP; CFH; COL4A3; COL4A4; COL4A5; COQ2; COQ6; COQ7; COQ8 (ADCK4); COQ9; CRB2; CUBN; CYP11B2; CYP24A1; DGKE; E2F3; EMP2; FAM161B; INF2; ITGA3; ITGB4; KANK2; LAMB2; LMX1B; MED28; MEFV; MYH9; MYO1E; NEIL1; NPHS1; NPHS2; PDSS2; PLCE1; PMM2; PTPRO; SCARB2; SMARCAL1; TRPC6; WT1; ZMPSTE24 Prior genetic testing results (if completed at an outside lab please attach report): BAF-Related Disorders Family history (if familial mutation is known, please specify; and BAF-related disorders panel include pedigree if available): ACTL6A; ARID1A; ARID1B; ARID2; DPF2; PHF6; SMARCA2; SMARCA4; SMARCB1; SMARCE1; SOX11
Leukodystrophies Leukodystrophy related disorders panel AARS1; AARS2; DARS1; DARS2; EARS2; FAM126A; GJC2; HEPACAM; LMNB1; MARS2;MLC1; PLP1; POLR1C;POLR3A; POLR3B; RARS1; SLC16A2; TUBB4A
July 2019