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British Columbia Laboratory Requisition This Requisition Form, When Completed, Constitutes a Referral to Lifelabs/BC Biomedical Laboratories Physicians

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British Columbia Laboratory Requisition This Requisition Form, When Completed, Constitutes a Referral to Lifelabs/BC Biomedical Laboratories Physicians 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany British Columbia Laboratory Requisition This requisition form, when completed, constitutes a referral to LifeLabs/BC Biomedical Laboratories physicians. Please ship NON-PRENATAL SAMPLES to: LIFELABS • Attn: CDS Department 100 International Boulevard• Toronto ON• M9W6J6 Attention Patient: Please visit your nearest LifeLabs or BCBiomedical Patient Service Centre for sample collection TO BE COMPLETED BY ORDERING DOCTOR AND PATIENT Patient Name (from CareCard or other ID) Gender Date of Birth Male Female YEAR MONTH DAY Patient Address Telephone Number Patient Email Bill to Patient: ✓(no charge at PSC) Doctor Name MSC # Organization Address Fax Number Telephone Number Email Copy to Genetic Test - mnemonic ACG (Blood sample 2 x 4mL EDTA) Genetic Test (Pediatric) - mnemonic CEN (Blood sample 1 x 2mL EDTA) Genetic Test (Other Sample Type) - mnemonic OCG (other sample type) PRENATAL SAMPLES: Please ship directly to CENTOGENE. Privacy Statement: The personal information collected on this form is collected under the authority of the Personal Information Protection act. The personal information is used to provide medical services requested on this requisition. The information collected is used for quality assurance management and disclosed to healthcare practitioners involved in providing care or when required or permitted by law. Personal information is protected from unauthorized use and disclosure in accordance with the Personal Information Protection act and when applicable the e-health act and/or the Freedom of Information and Protection of Privacy act and may be used and disclosed only as provided by those acts. our privacy policies are available at www.bcbio.com and www.lifelabs.com. 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(YY/MM/DD): 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(YY/MM/DD): For appointments at LifeLabs Patient Service Centres please call 1-855-412-4495. For appointments at BC Biomedical Patient Service Centres please call 1-877-507-5595 Date Doctor Signature YEAR MONTH DAY TO BE COMPLETED BY LABORATORY STAFF Date /Time of Collection Phlebotomist YEAR MONTH DAY **Laboratory Staff: Photocopy Requisition and include one copy with samples in box** LL-GCG-001 - Ver 2 – JAN 2015 Page 1/7 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 V3 Jan 2015 GENETIC TESTING REQUISITION SKIN, BONE & IMMUNE SYSTEM 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) LifeLabs Demographic Label □ 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 2/7 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 V3 Jan 2015 GENETIC TESTING REQUISITION SKIN, BONE & IMMUNE SYSTEM 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), Sequencing (S), and/or Deletion/Duplication (D) analysis Disorders of Skin, Teeth, & Hair NGS Panels: S Congenital ichthyosis panel (ABCA12, ALOX12B, ALOXE3, CERS3, CYP4F22, LIPN, NIPAL4, PNPLA1, TGM1) S Epidermolysis bullosa panel (COL17A1, LAMA3, LAMB3, LAMC2) Single genes: H D S Acne inversa familial type 3 (PSEN1) D S Epidermolytic palmoplantar keratoderma (KRT9) Erythroderma, congenital, with palmoplantar keratoderma, hypotrichosis and D S Adams-Oliver syndrome type 1 (ARHGAP31) D S hyper IgE (DSG1) D S Adams-Oliver syndrome type 2 (DOCK6) D S Erythrokeratodermia variabilis et progressiva (GJB3) D S Adams-Oliver syndrome type 3 (RBPJ) D S Erythrokeratodermia variabilis et progressiva (GJB4) D S Ankyloblepharon-ectodermal defects-cleft lip/palate (TP63) D S Focal dermal hypoplasia (PORCN) D S Albinism oculocutaneous nonsyndromic (SLC24A5) D S Griscelli syndrome type 1 (MYO5A) H D S Albinism, oculocutaneous type 1A (TYR) D S Griscelli syndrome type 3 (MLPH) H D S Albinism, oculocutaneous type 1B (TYR) D S Haim-Munk syndrome (CTSC) H D S Albinism, oculocutaneous type 2 (OCA2) D S Hyaline fibromatosis syndrome (ANTXR2) H D S Albinism, oculocutaneous type 2 (OCA2) D S Hypotrichosis Type 7 (LIPH) D S Albinism, oculocutaneous type 3 (TYRP1) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (ALOX12B) H D S Albinism, oculocutaneous type 4 (SLC45A2) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (ALOXE3) D S Albinism oculocutaneous type 5 (C10ORF11) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (NIPAL4) H D S Amelogenesis imperfecta (DLX3) D S Ichthyosiform erythroderma, congenital, nonbullous type 1 (TGM1) D S Autosomal dominant woolly hair with hypotrichosis (KRT71) D S Ichthyosis congenita, Harlequin fetus type (ABCA12) D S Autosomal dominant woolly hair with hypotrichosis (KRT74) D S Ichthyosis congenital, autosomal recessive type 9 (CERS3) D S Bjornstad syndrome (BCS1L) D S Ichthyosis congenital, autosomal recessive PNPLA1 related (PNPLA1) Cerebral dysgenesis, neuropathy, ichthyosis, palmoplantar keratoderma syndrome D S (SNAP29) D S Ichthyosis follicularis, atricia, and photophobia syndrome (MBTPS2) D S Chediak-Higashi syndrome (LYST) D S Ichthyosis prematurity syndrome (SLC27A4) D S CHIME syndrome (PIGL) H D S Ichthyosis vulgaris (FLG) D S Corneal intraepithelial dyskeratosis and ectodermal dysplasia (NLRP1) D S Ichthyosis, bullous type (KRT2) D S Craniosynostosis and dental anomalies (IL11RA) D S Ichthyosis, lamellar type 1 (TGM1) D S Cutis laxa type 1B (EFEMP2) D S Ichthyosis, lamellar type 2 (ABCA12) D S Cutis laxa type 2B (PYCR1) D S Ichthyosis, lamellar type 3 (CYP4F22) D S Cutis laxa type 3B (PYCR1)
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