PRENATAL TESTING REQUISITION Please place green collection kit SPECIMENS: 1428 Madison Ave., Rm AB2-25, New York, NY 10029 Phone: 800-298-6470 / Fax: 212-241-0139 barcode here. Tax ID# 47-5349024/ CLIA# 33D2097541 123456-2-X

Please fill out all the highlighted fields. Failure to do so may result in delayed testing and delivery of results.

PATIENT INFORMATION ORDERING PHYSICIAN INFORMATION Sema4 will use this information to contact the patient via automatic email, SMS, and/or phone regarding payment, testing NAME GENETIC COUNSELOR status, and online results access. By submitting this requisition, I confirm that I have obtained the patient’s authorization to REQUIRED be contacted by Sema4 by these means (email address must be specific to patient listed on form). ADDRESS CLINIC / INSTITUTION PATIENT EMAIL ADDRESS PATIENT MOBILE/PRIMARY NUMBER REQUIRED RECOMMENDED REQUIRED LAST NAME FIRST NAME MI REQUIRED TELEPHONE REQUIRED REQUIRED DATE OF BIRTH BIOLOGICAL GENDER PATIENT IS A SPERM/EGG DONOR FAX MM / DD / YYYY M F REQUIRED YES NO PARTNER / SPOUSE LAST NAME PARTNER / SPOUSE FIRST NAME PHYSICIAN SIGNATURE OF CONSENT (REQUIRED): I certify that this patient (and/or their legal guardian, as necessary) has been informed of the benefits, risks, and limitations of the laboratory test(s) requested. I have answered this person’s questions. CLIENT MRN PARTNER / SPOUSE DATE OF BIRTH I have obtained a signed informed consent from this patient or their legal guardian for this testing in accordance with applicable MM / DD / YYYY laws and regulations, including N.Y. Civil Rights Law Section 79-L, and will retain this consent in the patient’s medical record. ADDRESS CITY / STATE / ZIP SIGNATURE DATE MM / DD / YYYY REQUIRED REQUIRED INDICATIONS FOR TESTING ICD10 Dx CODE(S) (Required) O28.5 Abnormal chromosomal and genetic finding on BILLING INFORMATION O09.511 Advanced Maternal Age, First Trimester antenatal screening of mother Bill to: Client/Institution Insurance Self Pay/No Insurance O09.512 Advanced Maternal Age, Second Trimester N46 Male infertility POLICYHOLDER LAST NAME POLICYHOLDER FIRST NAME POLICYHOLDER DOB N96 Recurrent pregnancy loss N97 Female infertility REQUIRED REQUIRED MM / DD / YYYY Z82.7 Family history of congenital malformations, Z31.430 Encounter of female for testing for genetic INSURANCE CARRIER INSURANCE ID GROUP NO. deformations, and chromosomal abnormalities disease carrier status for procreative management REQUIRED REQUIRED REQUIRED Z84.81 Family history of carrier of genetic disease Z31.440 Encounter of male for testing for genetic O28.3 Abnormal ultrasonic finding on antenatal disease carrier for procreative management BILLING ADDRESS screening of mother O02.89 Other abnormal products of conception REQUIRED Other______SECONDARY INSURANCE YES NO COLLECTION DATE ___ /___ /___ # OF BLOOD TUBES SENT: YELLOW____ PURPLE____ BCT____ GREEN____ SECONDARY INSURANCE NAME GROUP NO. SPECIMEN TYPE: (Please contact laboratory for alternate specimen types) Pre-Authorization #: ______Please include a copy of all insurance paperwork. Maternal: Peripheral Blood Saliva Other______Paternal: Peripheral Blood Saliva Other______ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits be paid directly to the provider and I understand that I am Fetal: Amniotic Fluid Chorionic Villi POC Other______financially responsible for uncovered services. I also authorize the release of any information required to process the claim. Bill- ing inquiries, please call 800-298-6470, Option 3. PREGNANCY HISTORY: Gestational Age: _____Weeks _____Days or EDD: ____ /____ /____ (Required for fetal samples.) SIGNATURE DATE MM / DD / YYYY Pregnancy conceived: IVF Egg donor/gestational carrier Age of genetic mother (at time of retrieval):______

LABORATORY TEST(S) ORDERED Test Selection (Required) Parental Carrier Screening Infertility/Pregnancy Loss Carrier Screening Clinical Information: Test for Microdeletions of Y Chromosome (male) Thrombophilia Test (2 variants below) Patient ancestry: Preferred Language: Cystic Fibrosis with CFTR Intron 9 PolyT (male) F2 - c.*97G>A F5 - c.1601G>A (p.Arg534Gln) History of BMT or recent blood transfusion in the last 4 weeks? YES NO MTHFR - c.665C>T (p.Ala222Val) add-on Is the patient or their partner pregnant? YES NO Cytogenetics and Cytogenomics Is the patient currently using birth control medication? YES NO Previous carrier screening? YES NO CHROMOSOME ANALYSIS If yes, what gene/variant: Chromosome Analysis (includes AFP with amniotic fluid) Additional Cell Culture: Hold Grow Family History of: Partner Carrier of: Includes reflex to array if no growth for POC specimens Mosaicism study Reflex to array if normal chromosomes (select option below) Expanded Carrier Screen (283 genes) X-Linked Supplemental Panel (21 genes) Standard Pan-ethnic Panel (4 genes) Single Gene Variant(s) CHROMOSOMAL MICROARRAY: Array Comparative Genomic Hybridization (aCGH) 180K + SNP High Frequency Pan-ethnic Panel (11 genes) Phase analysis PGT set-up For prenatal specimens, please submit maternal blood for Maternal Cell Contamination (MCC) For all specimens, ECS 39 (39 genes) please include blood (1 EDTA purple top, 1 Sodium heparin green top) from parents of the proband/pregnancy for array Test only for AR disorders partner screened positive for - hold ECS 152 (152 genes) follow up if available sample pending partner results (mark on reverse side or list Comprehensive Jewish Carrier Screen (lower resolution) here): Prenatal Chromosomal Microarray (101 genes) High Resolution Chromosomal Microarray prenatal/postnatal/POC Ashkenazi Jewish Disorders (47+17 genes) NGS re-analysis of ECS 281 + enhancements included in Sephardi-Mizrahi Jewish Disorders ECS 283. Previous test order date: ____/____/____ POC Microarray Plus: Includes high resolution microarray analysis, triploidy detection, UPD analysis, (37+17 genes) Other molar pregnancy analysis and MCC studies with submission of maternal blood or saliva sample. Parental array followup NONINVASIVE PRENATAL TEST (NIPT) MENU - select only one Proband SEMA4 Lab ID: ______Name: ______DOB: ______ MaterniT® GENOME MaterniT21® PLUS Genome-wide fetal aneuploidies Select fetal aneuploidies (singleton only)  Core (chr 21, 18, 13, sex) FLUORESCENT in situ HYBRIDIZATION (FISH)  Core +ESS* Aneuploidy FISH (chromosomes 13,18,21,X,Y)  Core + SCA** 1p36 deletion syndrome (1p36.3) Prader-Willi/Angelman (15q11.2)  Core + ESS + SCA 22q deletion/DiGeorge syndrome (22q11.2) Rubenstein-Taybi syndrome (16p13.3) *ESS = chr 16, chr 22, and select microdeletions **SCA = sex chromosome aneuploidies CHARGE syndrome (8q12.1-q12.2) Smith-Magenis syndrome (17p11.2) REQUIRED CLINICAL INFORMATION Cri-du-chat syndrome (5p15.2) Sotos syndrome (5q35) Specimen Required: Two 10 mL Whole Blood BCT Streck Tubes Kallman syndrome (Xp22.3) STS deficiency (Xp22.3) Gestational age: ______weeks ______days orEDD: _____ / _____ / _____ Langer-Giedion syndrome (8q23.3-q24.11) Williams syndrome (7q11.23) Miller-Dieker syndrome (17p13.3) Wolf-Hirschhorn syndrome (4p16.3) Gestation  Singleton  Twins  Triplets  Other:______SRY (Yp11.3) FISH other: ______Maternal height: ______ft. ______in. Maternal weight: ______lbs.

MEDICAL INDICATION FOR TESTING Select one or more ICD10 codes Prenatal Diagnostic Testing FGFR3 Hotspot Panel High risk for fetal chromosomal aneuploidies Maternal Cell Contamination st nd rd reflex to sequencing if negative Maternal age: Primigravida  O09.511 1 tri  O09.512 2 tri  O09.513 3 tri Other: Multigravida  O09.521 1st tri  O09.522 2nd tri  O09.523 3rd tri Limb Defects Next Gen Sequencing Panel (7 genes) Noonan Syndrome Next Gen Sequencing Panel (19 genes) Abnormal serum biochemical screening:  O28.1 Single gene/Diagnostic testing Ultrasound finding: (specify type[s] in Comments)  O35.1XX0 Gene: Targeted testing: Maternal variant:______Paternal variant: ______Personal family history (specify type in Comments) Prior pregnancy with trisomy  O09.291 1st tri  O09.292 2nd tri  O09.293 3rd tri Biochemical testing: Tay-Sachs enzyme analysis Sandhoff enzyme analysis Robertsonian translocation  Q95.0  Q95.1 • Maternal blood is required for all prenatal specimens for maternal cell contamination. Other high risk factor: ICD10 code______• If patient/partner was NOT tested at Sema4, parental bloods are required (5-10mL EDTA) to confirm the variant No known high risk for fetal chomosomal aneuploidies(MaterniT21 PLUS or VisibiliT only) in-house. Please also provide a copy of any previous results.  Z34.91 1st tri  Z34.92 2nd tri  Z34.93 3rd tri  Other ICD10 code:______• Please contact the laboratory for all prenatal molecular/biochemical testing

COMPLETE AND SUBMIT ALL PAGES TO LABORATORY PAGE 1 of 3 FFP0092GE0420 Expanded Carrier Screen Panel includes: Abetalipoproteinemia u l t Corticosterone Methyloxidase Deficiency u n t Leber Congenital Amaurosis 8 / Retinitis Pigmentosa 12 / Niemann-Pick Disease, Type C (NPC2-Related) Achromatopsia t Cystic Fibrosis w s u l n @ t Pigmented Paravenous Chorioretinal Atrophy Nijmegen Breakage Syndrome Acrodermatitis Enteropathica Cystinosis u n t Leigh Syndrome, French-Canadian Type t Non-Syndromic Hearing Loss (GJB2-Related) u l t Acute Infantile Liver Failure u n t D-Bifunctional Protein Deficiency Lethal Congenital Contracture Syndrome 1 / Lethal Odonto-Onycho-Dermal Dysplasia / Arthrogryposis with Anterior Horn Cell Disease t Acyl-CoA Oxidase I Deficiency Deafness, Autosomal Recessive 77 u l t Schopf-Schulz-Passarge Syndrome Leukoencephalopathy with Vanishing White Matter Adenosine Deaminase Deficiency t Duchenne Muscular Dystrophy / Omenn Syndrome (RAG2-Related) u n t Limb-Girdle Muscular Dystrophy, Type 2A Adrenoleukodystrophy, X-Linked u n t Becker Muscular Dystrophy s @ u l n t Omenn Syndrome / Severe Combined Immunodeficiency, Limb-Girdle Muscular Dystrophy, Type 2B u n t Athabaskan-Type Aicardi-Goutières Syndrome (SAMHD1-Related) Dyskeratosis Congenita (RTEL1-Related) u l t Ornithine Aminotransferase Deficiency u n t Alpha-Mannosidosis Dystrophic Epidermolysis Bullosa t Limb-Girdle Muscular Dystrophy, Type 2C Ornithine Transcarbomylase Deficiency Alpha-Thalassemia s @ u l n t Ehlers-Danlos Syndrome, Type VIIC u l t Limb-Girdle Muscular Dystrophy, Type 2D Osteopetrosis 1 u l t Alpha-Thalassemia Mental Retardation Syndrome Ellis-van Creveld Syndrome (EVC-Related) t Limb-Girdle Muscular Dystrophy, Type 2E Pendred Syndrome t Alport Syndrome (COL4A3-Related) u l t Emery-Dreifuss Myopathy 1 Limb-Girdle Muscular Dystrophy, Type 2I u l @ t Phenylalanine Hydroxylase Deficiency s u l n @ t Alport Syndrome (COL4A4-Related) Enhanced S-Cone Syndrome u l t Lipoamide Dehydrogenase Deficiency 3-Phosphoglycerate Dehydrogenase Deficiency u l t Alport Syndrome (COL4A5-Related) Ethylmalonic Encephalopathy Lipoid Adrenal Hyperplasia Polycystic Kidney Disease, Autosomal Recessive u l @ t Alstrom Syndrome Fabry Disease Lipoprotein Lipase Deficiency Polyglandular Autoimmune Syndrome, Type 1 u n t Andermann Syndrome t Factor IX Deficiency Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency Pontocerebellar Hypoplasia, Type 1A u l t Argininosuccinic Aciduria t Factor XI Deficiency u l t Lysinuric Protein Intolerance @ t Pontocerebellar Hypoplasia, Type 6 u n t Aromatase Deficiency Familial Autosomal Recessive Hypercholesterolemia u Maple Syrup Urine Disease, Type 1a u l @ t Primary Carnitine Deficiency t Arthrogryposis, Mental Retardation, and Seizures u l t Familial Dysautonomia u l @ t Maple Syrup Urine Disease, Type 1b Primary Ciliary Dyskinesia (DNAH5-Related) u l t Asparagine Synthetase Deficiency u n t Familial Hypercholesterolemia lt Meckel-Gruber syndrome 1 / Bardet-Biedl Syndrome 13 t Primary Ciliary Dyskinesia (DNAI1-Related) u l t Aspartylglycosaminuria t Familial Hyperinsulinism (ABCC8-Related) u l @ t Medium Chain Acyl-CoA Dehydrogenase Deficiencys@tlnt Primary Ciliary Dyskinesia (DNAI2-related) u l t Ataxia With Isolated Vitamin E Deficiency Familial Hyperinsulinism (KCNJ11-Related) t Megalencephalic Leukoencephalopathy with Subcortical Cysts Primary Hyperoxaluria, Type 1 Ataxia-Telangiectasia u n t Familial Mediterranean Fever u l n t u n t Primary Hyperoxaluria, Type 2 Autosomal Recessive Spastic Ataxia of Fanconi Anemia, Group A u n t Menkes Disease u l t Charlevoix-Saguenay t Fanconi Anemia, Group C u l @ t Primary Hyperoxaluria, Type 3 Metachromatic Leukodystrophy u n t u n t Bardet-Biedl Syndrome (BBS10-Related) Fanconi Anemia, Group G t Progressive Cerebello-Cerebral Atrophy 3-Methylcrotonyl-CoA Carboxylase Deficiency: Bardet-Biedl Syndrome (BBS12-Related) Fragile X Syndrome w s u l n @ t Progressive Familial Intrahepatic Cholestasis, (MCCC1-Related) Type 2 Bardet-Biedl Syndrome (BBS1-Related) t Fumarase Deficiency t 3-Methylcrotonyl-CoA Carboxylase Deficiency: Propionic Acidemia (PCCA-Related) Bardet-Biedl Syndrome (BBS2-Related) u l t Galactokinase Deficiency t (MCCC2-Related) Propionic Acidemia (PCCB-Related) Bare Lymphocyte Syndrome, Type II Galactosemia u l @ t 3-Methylglutaconic Aciduria, Type III / Bartter Syndrome, Type 4A u l @ t Pycnodysostosis Gaucher Disease Optic Atrophy 3, with Cataract u n t Bernard-Soulier Syndrome, Type A1 t Pyruvate Dehydrogenase E1-Alpha Deficiency Gitelman Syndrome Methylmalonic Acidemia (MMAA-Related) Pyruvate Dehydrogenase E1-Beta Deficiency Bernard-Soulier Syndrome, Type C Glutaric Acidemia, Type I t Methylmalonic Acidemia (MMAB-Related) 3-Beta-Hydroxysteroid Dehydrogenase Type II Deficiency 6-Pyruvoyl-Tetrahydropterin Synthase Deficiency Glutaric Acidemia, Type IIa Methylmalonic Acidemia (MUT-Related) Renal Tubular Acidosis and Deafness u n t Beta-Ketothiolase Deficiency Glutaric Acidemia, Type IIc t Methylmalonic Aciduria and Homocystinuria, Cobalamin C Retinitis Pigmentosa 25 u n t Beta-Globin-Related Hemoglobinopathies s u n l @ t Glycine Encephalopathy (AMT-Related) Type v Retinitis Pigmentosa 26 u n t Bilateral Frontoparietal Polymicrogyria Glycine Encephalopathy (GLDC-Related) Methylmalonic Aciduria and Homocystinuria, Cobalamin D Type u l n t Biotinidase Deficiency t u l @ t Retinitis Pigmentosa 28 Glycogen Storage Disease, Type Ia Microphthalmia / Anophthalmiau n t Bloom Syndrome u l @ t Retinitis Pigmentosa 59 u l t Glycogen Storage Disease, Type Ib Mitochondrial Complex I Deficiency Rhizomelic Chondrodysplasia Punctata, Type 1 v Canavan Disease u l @ t Glycogen Storage Disease, Type II u l n t (ACAD9-Related) Rhizomelic Chondrodysplasia Punctata, Type 3 Carbamoylphosphate Synthetase I Deficiency Glycogen Storage Disease, Type III u n t Mitochondrial Complex I Deficiency Roberts Syndrome Carnitine Palmitoyltransferase IA Deficiency Glycogen Storage Disease, Type IV / (NDUFAF5-Related) u l t Salla Disease t Carnitine Palmitoyltransferase II Deficiency u l t Adult Polyglucosan Body Disease u l t Mitochondrial Complex I Deficiency Sandhoff Disease t Carpenter Syndrome Glycogen Storage Disease, Type V u n t (NDUFS6-Related) u n t Schimke Immunoosseous Dysplasia Cartilage-Hair Hypoplasia t Glycogen Storage Disease, Type VII u l t Mitochondrial DNA Depletion Syndrome 6 / Segawa Syndrome Cerebral Creatine Deficiency Syndrome 1 GRACILE Syndrome and Navajo Neurohepatopathy u n t Sjogren-Larsson Syndrome Cerebral Creatine Deficiency Syndrome 2 Other BCS1L-Related Disorders t Mitochondrial Myopathy and Sideroblastic Anemia 1 t Smith-Lemli-Opitz Syndrome w s u l n @ t Cerebrotendinous Xanthomatosis u n t Hemochromatosis, Type 2A Mucolipidosis II / IIIA Spinal Muscular Atrophy (includes Enhanced Charcot-Marie-Tooth Disease, Type 4D Hemochromatosis, Type 3 Mucolipidosis III Gamma u l @ t SMA Testing) w s u l n @ t Charcot-Marie-Tooth Disease, Type 5 / Hereditary Fructose Intolerance t Mucolipidosis IV Spondylothoracic Dysostosis Arts syndrome Hereditary Spastic Paraparesis 49 u n t Mucopolysaccharidosis Type I @ Steel Syndrome Charcot-Marie-Tooth Disease, X-Linked Hermansky-Pudlak Syndrome, Type 1 t Mucopolysaccharidosis Type II Stuve-Wiedemann Syndrome Choreoacanthocytosis u l t Hermansky-Pudlak Syndrome, Type 3 u l t Mucopolysaccharidosis Type IIIA Sulfate Transporter-Related Choroideremia HMG-CoA Lyase Deficiency Mucopolysaccharidosis Type IIIB Osteochondrodysplasia t Chronic Granulomatous Disease (CYBA-related) u n t Holocarboxylase Synthetase Deficiency t Mucopolysaccharidosis Type IIIC Tay-Sachs Disease u l n @ t Chronic Granulomatous Disease (CYBB-related) Homocystinuria (CBS-Related) t Mucopolysaccharidosis Type IIID Tyrosinemia, Type I u l @ t Citrin Deficiency t Homocystinuria due to MTHFR Deficiency u n t Mucopolysaccharidosis Type IVb / t Usher Syndrome, Type IB t Citrullinemia, Type 1 @ Homocystinuria, cblE Type GM1 Gangliosidosis Usher Syndrome, Type IC t Cohen Syndrome Hydrolethalus Syndrome t Mucopolysaccharidosis type VI Usher Syndrome, Type ID t Combined Malonic and Methylmalonic Aciduria t Hyperornithinemia-Hyperammonemia-Homocitrullinuria Mucopolysaccharidosis type IX Usher Syndrome, Type IF u l @ t Combined Oxidative Phosphorylation Syndrome Multiple Sulfatase Deficiency u l t Usher Syndrome, Type IIA u n t Deficiency 1 Hypohidrotic Ectodermal Dysplasia 1 Muscle-Eye-Brain Disease and Usher Syndrome, Type III u l @ t Combined Oxidative Phosphorylation Hypophosphatasia t Other POMGNT1-Related Congenital Muscular Dystrophy-Dystroglycanopathies t Very Long Chain Acyl-CoA Dehydrogenase Deficiency t Deficiency 3 t Inclusion Body Myopathy 2 u n t Myoneurogastrointestinal Encephalopathyu n t Walker-Warburg Syndrome and Combined Pituitary Hormone Deficiency 2 t Infantile Cerebral and Cerebellar Atrophy u n t Myotubular Myopathy 1 Other FKTN-Related Dystrophies u l @ t Combined Pituitary Hormone Deficiency 3 Isovaleric Acidemia @ N-Acetylglutamate Synthase Deficiency Wilson Disease u l n t Combined SAP Deficiency Joubert Syndrome 2 u l @ t Nemaline Myopathy 2 u l @ t Wolman Disease / Cholesteryl Ester Storage Disease u n t Congenital Adrenal Hyperplasia due to Joubert Syndrome 7 / Meckel Syndrome 5 / 17-Alpha-Hydroxylase Deficiency COACH Syndrome Nephrogenic Diabetes Insipidus, Type II X-Linked Juvenile Retinoschisis X-Linked Severe Combined Immunodeficiency Congenital Adrenal Hyperplasia due to Junctional Epidermolysis Bullosa Nephrotic Syndrome (NPHS1-Related) / 21-Alpha-Hydroxylase Deficiency u l n (LAMA3-Related) Congenital Finnish Nephrosis t Zellweger Syndrome Spectrum (PEX10-Related) @ Congenital Amegakaryocytic Thrombocytopenia u l t Junctional Epidermolysis Bullosa Nephrotic Syndrome (NPHS2-Related) / Zellweger Syndrome Spectrum (PEX1-Related) Congenital Disorder of Glycosylation, Type Ia su l @ n t (LAMB3-Related) Steroid-Resistant Nephrotic Syndrome Zellweger Syndrome Spectrum (PEX2-Related) u l t Congenital Disorder of Glycosylation, Type Ib Junctional Epidermolysis Bullosa Neuronal Ceroid-Lipofuscinosis (CLN3-Related) @ Zellweger Syndrome Spectrum (PEX6-Related) u n t Congenital Disorder of Glycosylation, Type Ic (LAMC2-Related) Neuronal Ceroid-Lipofuscinosis (CLN5-Related) t Congenital Insensitivity to Pain with Anhidrosis u n t Krabbe Disease t Neuronal Ceroid-Lipofuscinosis (CLN6-Related) Congenital Myasthenic Syndrome Lamellar Ichthyosis, Type 1 t Neuronal Ceroid-Lipofuscinosis (CLN8-Related) KEY FOR SMALLER PANELS (CHRNE-Related) Leber Congenital Amaurosis 10 and Neuronal Ceroid-Lipofuscinosis w Standard @ ECS 39 Other CEP290-Related Ciliopathies t (MFSD8-Related) Congenital Myasthenic Syndrome s High Frequency t ECS 152 (RAPSN-Related) u n t Leber Congenital Amaurosis 13 Neuronal Ceroid-Lipofuscinosis (PPT1-Related) t u Comprehensive Jewish Congenital Neutropenia (HAX1-Related) Leber Congenital Amaurosis 2 / Retinitis Pigmentosa 20 u n t Neuronal Ceroid-Lipofuscinosis (TPP1-Related) t l Ashkenazi Jewish Disorders Congenital Neutropenia (VPS45-Related) Leber Congenital Amaurosis 5 Niemann-Pick Disease A/B (SMPD1-Related) u l @ t n Sephardi-Mizrahi Jewish Disorders rev 1218 Corneal Dystrophy and Perceptive Deafness Niemann-Pick Disease, Type C (NPC1-Related) COMPLETE AND SUBMIT ALL PAGES TO LABORATORY PAGE 2 OF 3 Informed Consent for Genetic Testing

I, , hereby request genetic testing, which may include molecular, cytogenetic and/or biochemical analyses, for Myself My child I have received verbal and written information (please see sema4.com/testcatalog for test-specific information sheet) from my physician or from a genetic counselor that described, in words that I understood, the nature of the genetic testing that I/my child am about to undergo. I understand that specimen(s), such as a peripheral blood, saliva, cheek swab, dried blood spot, skin biopsy, amniotic fluid, chorionic villi and/or urine sample, will be taken from me/my child. I understand that the samples will be used for determining if I/my child have a genetic disease, are carriers of a genetic disease, or are more likely to develop a genetic disease or condition. The nature of the genetic test(s) that have been ordered in connection with this consent has been explained to me and the accuracy of the test and its risks and limitations have been detailed. I understand that infrequent errors may occur, even though the likelihood of an incorrect diagnosis or a misinterpretation of the result is extremely small. The likelihood of this occurring has been estimated to be less than 1%. I understand that a negative result reduces, but does not eliminate, the possibility that I/my child carry a mutation(s) in the gene(s) analyzed or in other gene(s) that are not included in the test. I understand that no test will be performed on my sample other than the one(s) authorized by me and my healthcare provider. I have reviewed the test order made in connection with this consent, and I hereby give consent to have my specimen tested as set forth in the order. De-identified research Sema4 may de-identify and use all data and information generated and received in connection with this test to support medical and academic research relating to health, disease prevention, drug development, and other scientific purposes, and I will receive no compensation in connection with such research. Data and information are “de-identified” by removing any information that could be used to identify a specific person, such as a name, email address, or date of birth. Sema4 may also give the de-identified data and information to its research partners and may submit it to research databases for use in scientific and medical research, including scientific databases that are maintained by the federal government, such as a database kept by the National Institutes of Health (“NIH”) (an agency of the federal government that funds research). Researchers have to apply to the NIH to see the information in the database. If I do not want to have any of my de-identified data and information used in research consistent with this consent, I may initial here______, or I may withdraw this consent by contacting Sema4, including by emailing [email protected]. Permission to contact I understand that Sema4 may wish to contact me/my child in the future, including for the following reasons: research purposes, the provision of general information about research findings, and/or the provision of information about the results of tests on my/my child’s sample(s). I understand that I may notify Sema4 to opt out of such future contact, including by emailing [email protected].

I understand that Sema4 may wish to contact me/my child in the future, including for the following reasons: research purposes, the provision of general information about research findings, and/or the provision of information about the results of tests on my/my child’s sample(s). I understand that I may notify Sema4 to opt out of such future contact, including by emailing [email protected]. I understand that this testing may yield results that are of unknown clinical significance and that parental or other relative’s specimens may also be tested to determine whether a specific finding was inherited. In addition, incidental findings that are not related to the primary diagnosis may be identified in me/my child. An error in the diagnosis may occur if the true biological relationships of the family members involved are not as I have stated and this test may detect non- paternity. The results of my/my child’s test will be explained to me by a genetic counselor or by my physician who will have the opportunity to discuss my results with a geneticist. I have had the opportunity to have all of my questions answered. If I am signing this form on behalf of a minor for whom I am the legal guardian, I am satisfied that I have received enough information to sign on his or her behalf. I understand that this consent is being obtained in order to protect my right to have all of my questions answered before testing. I understand that the results of this testing will become part of my medical record and may only be disclosed to individuals who have legal access to this record or to individuals who I designate to receive this information.

Signature of person being tested (or guardian) Date

Rev.04/17/2020

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