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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 LL: K012-01/ CML: CEN CONTRACT # Report to Physician Billing # LifeLabs Demographic Ordering Physician Name Label 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 1/12 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 Jan2015 GENETIC TESTING REQUISITION NEUROMUSCULAR & DEVELOPMENTAL DELAY 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 □ Saliva (Oragene OG-510: Available by request) Label □ 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 2/12 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 Jan2015 GENETIC TESTING REQUISITION NEUROMUSCULAR & DEVELOPMENTAL DELAY 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 Hereditary Polyneuropathies & ALS NGS Panels: (ALS2, ANG, ATXN2, C9orf72, CHMP2B, CHGB, DCTN1, FIG4, FUS, NEFH, OPTN, PFN1, PRPH2, SETX, SIGMAR1, SOD1, SPG20, D S Amyotrophic lateral sclerosis (ALS) panel TARDBP, UBQLN2, VAPB, VCP, VEGFA, VPS54) CMT neuropathy axonal autosomal (AARS, ARHGEF10, DNM2, GAN, GARS, GDAP1, DYNC1H1, HSPB8, HSPB1, KIF1B, LMNA, MED25, MFN2, MPZ, NEFL, RAB7A, D S dominant panel SLC12A6, TRPV4, YARS) D S CMT neuropathy demyelinating panel (CTDP1, EGR2, FGD4, FIG4, GDPA1, GJB1, LITAF, MTMR2, MPZ, NDRG1, NEFL, PMP22, PRPS1, PRX, SBF2, SH3TC2) D S Dejerine-Sottas syndrome panel (MPZ, PMP22, PRX, EGR2, GJB1) Single genes: D S Agenesis of the corpus callosum with peripheral neuropathy (SLC12A6) D S Charcot Marie Tooth type 4-CTDP1 related (CTDP1) D S Amyloidosis (TTR) D S Charcot Marie Tooth type 4A (GDAP1) D S Amyloidosis, finnish type (GSN) D S Charcot Marie Tooth type 4B1 (MTMR2) D S Amyotrophic lateral sclerosis CREST related (SS18L1) D S Charcot Marie Tooth type 4B2 (SBF2) D S Amyotrophic lateral sclerosis risk factor (CHGB) D S Charcot Marie Tooth type 4C (SH3TC2) D S Amyotrophic lateral sclerosis type 1 (SOD1) D S Charcot Marie Tooth type 4D (NDRG1) D S Amyotrophic lateral sclerosis type 2 (ALS2) D S Charcot Marie Tooth type 4E (EGR2) D S Amyotrophic lateral sclerosis type 4 (SETX) H D S Charcot Marie Tooth type 4E (MPZ) D S Amyotrophic lateral sclerosis type 6 (FUS) H D S Charcot Marie Tooth type 4F (PRX) D S Amyotrophic lateral sclerosis type 8 (VAPB) D S Charcot Marie Tooth type 4H (FGD4) D S Amyotrophic lateral sclerosis type 9 (ANG) D S Charcot Marie Tooth type 4J (FIG4) D S Amyotrophic lateral sclerosis type 10 (TARDBP) D S Charcot Marie Tooth type X1 (GJB1) D S Amyotrophic lateral sclerosis type 11 (FIG4) H D S Charcot Marie Tooth type X5 (PRPS1) D S Amyotrophic lateral sclerosis type 12 (OPTN) H D S Dejerine-Sottas disease (MPZ) D S Amyotrophic lateral sclerosis type 14 (VCP) H D S Dejerine-Sottas disease (PMP22) D S Amyotrophic lateral sclerosis type 16 (SIGMAR1) H D S Dejerine-Sottas disease (PRX) D S Amyotrophic lateral sclerosis type 17 (CHMP2B) D S Dejerine-Sottas disease (EGR2) D S Amyotrophic lateral sclerosis type 18 (PFN1) D S Dejerine-Sottas disease (GJB1) D S Amyotrophic lateral sclerosis VPS54 related (VPS54) D S Distal hereditary motor neuropathy type 2A (HSPB8) E R Amyotrophic lateral sclerosis with frontotemporal dementia (C9orf72) D S Distal hereditary motor neuropathy type 2B (HSPB1) D S Amyotrophic lateral sclerosis, susceptibility to (NEFH) D S Distal hereditary motor neuropathy type 5 (GARS) D S Amyotrophic lateral sclerosis, x-linked juvenile and adult-onset ALS (UBQLN2) D S Distal hereditary motor neuropathyr type 6 (IGHMBP2) D S Cataracts with facial dysmorphism and neuropathy (CTDP1) D S Distal hereditary motor neuropathy type 7B (DCTN1) D S Charcot MarieTooth disease, dominant intermediate (GNB4) D S Distal hereditary motor neuropathy, X linked (ATP7A) D S Charcot MarieTooth disease, dominant intermediate B (DNM2) D S Distal hereditary motor neuropathy, autosomal recessive (DNAJB2) D S Charcot MarieTooth disease, dominant intermediate C (YARS) H D S Erythermalgia, primary
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