Download Requisition for DNA Testing

PagePage 1 1of of 5 3 LondonLondon Health Sciences Sciences Centre Centre – Molecular– (Molecular Diagnostics Genetics) Reason for Referral: Requisition for DNATesting Ph: 519-685-8122 |Fax: 519-685-8279 London, Ontario |N6A5W9 800 Commissioners Rd E. Victoria Hospital, Room B10-123A MOLECULAR GENETICS LABORATORY Clinical Diagnostics andFamily History: Sample Collection: Lab Use Only: CLINICAL DIAGNOSTICS ANDFAMILY HISTORY SAMPLE COLLECTION Ph: 519-685-8122 | Fax: 519-685-8279 London, Ontario |N6A 5W9 800 Commissioners Rd. E. Victoria Hospital, Room B10-123A Molecular Genetics Laboratory REASON FOR REFERRAL LAB USEONLY Requisition for DNA Testing Name of index case inthefamily RefSeq:NM: Gene: Relationship to thispatient: Date drawn: Date of Birth: Notes: Received date: Date drawn Relationship to thispatient: Date ofBirth: Referral to anoutsidelaboratory Mutation: Gene: LHSC MD#/Name ofIndex case inthe family Carriertesting/Known Family Mutation Unaffected Affected Diagnostic Testing: Notes: Received date: (slides preferred) Formalin fixed paraffin embeddedtissue(FFPE) Fresh/Frozen Tissue ug DNA (100ngto 1ug): EDTA bonemarrow (lavender top)(min. 2mlat room temp) Referral to anoutside laboratory RNA Banking DNA Banking FamilyCarrier testing/Known Mutation EDTA blood(lavender top)(min. 2mlat room temp) Prenatal Diagnosis Diagnostic Testing: Other: Fresh/Frozen Tissue EDTA blood Other: EDTA bonemarrow Formalin fixed paraffin embedded tissue DNA Prenatal Diagnosis Unaffected Affected

(100ng to 1ug) ( ) YYYY/MM/DD (YYYY/MM/DD) (lavender top)(min. 2mlat room temp) : ug (provide tissue source): tissue (provide

(lavender top)(min. 2mlat room temp) (provide tissuesource) : DNABanking RefSeq:NM: Mutation: (include copy of report): of copy (include

(must specify lab): specify (must

(must lab) specify

(include copy ofreport) (FFPE -slidespreferred) : RNABanking

Referring Physician: INCOMPLETE REQUESTS WILLBEBANKED Patient Information: Request for Expedited Result: Test Requests:

AUTHORIZED SIGNATURE ISREQUIRED TEST REQUESTS REFERRING PHYSICIAN REQUEST FOR EXPEDITEDRESULT PATIENT INFORMATION Telephone: Telephone: Address: E-mail address: Address: Name: Signature: Physician name(print): Medical intervention Medical intervention adjacent to theitem of interest. panelssub- orindividualgenes maybeselected usingthecheckbox Use attached menuto select panels orindividualgenes. Panels, CC report to: Health Card No.: Date ofBirth: Pregnancy using thecheckbox adjacent to theitem ofinterest. Panels, sub-panelsorindividualgenes may beselected Use attached menu to selectpanelsorindividual genes. Sex: M Address: Name: Telephone: Address: Name: CC report to: E-mail address: Telephone: Address: Signature: Physician Name(print): Medical Intervention Sex: Address: Birthdate: Name: Health Card Number: YYYY/MM/DD Pregnancy

F aeFemale Male

: YY/MM/DD) (L.M.P., (L.M.P., YYYY/MM/DD)

Other (specify with date): with (specify (specify withdate)(specify Pathology and LaboratoryMedicine

(INCOMPLETE REQUESTS WILLBEBANKED) Authorized Signature isRequired Fax: Fax:

F F : ax: ax:

NGSMGL(12/04/2017)

(03/17/2021)

PagePage 1 2of of 5 3 LondonLondon Health Sciences Sciences Centre Centre – Molecular– (Molecular Diagnostics Genetics) Reason for Referral: Requisition for DNATesting Ph: 519-685-8122 |Fax: 519-685-8279 London, Ontario |N6A5W9 800 Commissioners Rd E. Victoria Hospital, Room B10-123A MOLECULAR GENETICS LABORATORY Clinical Diagnostics andFamily History: Sample Collection: Lab Use Only: Ph: 519-685-8122 | Fax: 519-685-8279 London, Ontario |N6A 5W9 800 Commissioners Rd. E. Victoria Hospital, Room B10-123A Molecular Genetics Laboratory Requisition for DNA Testing FOR SAMPLE REQUIREMENTS SEE: NGS PANELS Name of index case inthefamily RefSeq:NM: Gene: Relationship to thispatient: Date drawn: Date of Birth: Notes: Received date: Charcot MarieTooth Requisitions can be found at https://www.lhsc.on.ca/palm/forms/requisitions.html#moldx Atypical Uremic Hemolytic Syndrome Epilepsy Hereditary CanerPanel (HCP) Please usethededicated requisitions for following gene panels: Nuclear encoded genes: Charcot MarieTooth -Individualselections Mitochondrial encoded genes: Mitochondrial GenomeandDepletion andIntegrity -Individualselections Mitochondrial Genome andDepletion/Integrity Panel (slides preferred) Formalin fixed paraffin embeddedtissue(FFPE) Fresh/Frozen Tissue ug DNA (100ngto 1ug): EDTA bonemarrow (lavender top)(min. 2mlat room temp) Referral to anoutside laboratory RNA Banking DNA Banking FamilyCarrier testing/Known Mutation EDTA blood(lavender top)(min. 2mlat room temp) Prenatal Diagnosis Diagnostic Testing: Other: Charcot MarieTooth, HNPP-Comprehensive (34) TRPV4 PDK3 LRSAM1 GDAP1 AARS SBF2,SPTLC1,PRPS1, RAB7A, TRPV4, TTR AARS, DYNC1H1, AIFM1,DNAJB2, FGD4, GARS, GDAP1, GJB1,HSPB1,HSPB8,IGHMBP2,KIF1B, LRSAM1, LMNA, MARS, MED25,MFN2,MPZ, MTMR2,NDRG1, PDK3, NEFL, Charcot MarieTooth -Type2 (28) EGR2, FIG4,GDAP1, GJB1,LITAF, MPZ, PMP22,PRX,SH3TC2 NEFL, Charcot MarieTooth -Type1 (10) SBF2,SH3TC2,NDRG1, PDK3,PMP22,PRPS1,PRX,RAB7A, NEFL, SPTLC1, TRPV4, TTR AARS, DYNC1H1, AIFM1,DNAJB2, EGR2, FGD4, FIG4,GARS, GDAP1, GJB1,HSPB1,HSPB8,IGHMBP2,KIF1B, LITAF, LRSAM1, LMNA, MARS, MED25,MFN2,MPZ, MTMR2, Mitochondrial GenomeandDepletion/Integrity Panel (56) OPA3 APTX TRNS2 TRNL1 TRNC ND3 ATP6 SUCLG1, TK2,TWNK,TYMP Nuclear encoded genes: TRNI, TRNK,TRNL1,TRNL2,TRNM,TRNN,TRNP, TRNR,TRNS,TRNS2,TRNT, TRNQ, TRNV, TRNW, TRNY Mitochondrial encoded genes: TK2 Unaffected Affected (isoform A&B) ( ) YYYY/MM/DD (INCLUDES DELETION/DUPLICATION ANALYSIS)

TTR PMP22 MARS GJB1 AIFM1 TRNT TRNL2 TRND ND4 ATP8 TWNK POLG DGUOK APTX, DGUOK,DNA2,FBXL4, GFER,MGME1,MPV17, OPA1, OPA3 (isoform A&B),POLG, POLG2, RRM2B, SLC25A4, SPG7(isoform 1&2),SUCLA2, (provide tissue source): tissue (provide (Ontario referrals -OnlyComprehensive Panel, andSPTLC1 available) TTR ATP6, ATP8, COX1, COX2, COX3, CYTB, TRNC, ND5,ND6,RNR1,RNR2,TRNA, TRND, ND1,ND2,ND3,ND4,ND4L, TRNE,TRNF, TRNG,TRNH, (C10 orf2) Mutation:

(include copy of report): of copy (include

(must specify lab): specify (must

PRPS1 MED25 HSPB1 DNAJB2 TRNV TRNM TRNE ND4L COX1 TYMP POLG2 DNA2 http://www.lhsc.on.ca/lab/molegen/index.htm PRX MFN2 HSPB8 DYNC1H1 TRNW TRNN TRNF ND5 COX2 RRM2B FBXL4 Referring Physician: INCOMPLETE REQUESTS WILLBEBANKED Patient Information: Request for Expedited Result: Test Requests:

AUTHORIZED SIGNATURE ISREQUIRED Telephone: Telephone: Address: E-mail address: Address: Name: Signature: Physician name(print): Medical intervention Medical intervention adjacent to theitem of interest. panelssub- orindividualgenes maybeselected usingthecheckbox Use attached menuto select panels orindividualgenes. Panels, CC report to: Sex: Address: Birthdate: Name: (Ontario referrals -OnlyComprehensive Panel available) Health Card Number: RAB7A MPZ IGHMBP2 EGR2 Pregnancy Patient Identifier: TRNY TRNP TRNG ND6 COX3 SLC25A4 GFER aeFemale Male

: YY/MM/DD) (L.M.P., SBF2 MTMR2 KIF1B FGD4 TRNQ TRNH RNR1 CYTB SPG7 MGME1 (specify with date): with (specify Pathology and LaboratoryMedicine (isoform A&B) Fax: Fax:

SH3TC2 NDRG1 LITAF FIG4 TRNR TRNI RNR2 ND1 SUCLA2 MPV17 NGSMGL(12/04/2017) (03/17/2021) SPTLC1 NEFL LMNA GARS TRNS TRNK TRNA ND2 SUCLG1 OPA1 PagePage 1 3of of 5 3 LondonLondon Health Sciences Sciences Centre Centre – Molecular– (Molecular Diagnostics Genetics) Reason for Referral: Requisition for DNATesting Ph: 519-685-8122 |Fax: 519-685-8279 London, Ontario |N6A5W9 800 Commissioners Rd E. Victoria Hospital, Room B10-123A MOLECULAR GENETICS LABORATORY Clinical Diagnostics andFamily History: Sample Collection: Lab Use Only: Ph: 519-685-8122 | Fax: 519-685-8279 London, Ontario |N6A 5W9 800 Commissioners Rd. E. Victoria Hospital, Room B10-123A Molecular Genetics Laboratory Requisitions can be found at https://www.lhsc.on.ca/palm/forms/requisitions.html#moldx Requisition for DNA Testing: Biochemical Genetics Hematologic Oncology Requisition Please usethefollowing dedicated requisitions for relevant assays: Requisition for DNA Testing TARGETED ASSAYS SINGLE GENES BY NGS NGS PANELS Name of index case inthefamily RefSeq:NM: Gene: Relationship to thispatient: Date drawn: Date of Birth: Notes: Received date: Urea Cycle Disorders -Individualselections Urea Cycle Disorders Lysosomal Storage Disorders Lysosomal Storage Disorders -Individualselections (slides preferred) Formalin fixed paraffin embeddedtissue(FFPE) Fresh/Frozen Tissue ug DNA (100ngto 1ug): EDTA bonemarrow (lavender top)(min. 2mlat room temp) Referral to anoutside laboratory RNA Banking DNA Banking FamilyCarrier testing/Known Mutation EDTA blood(lavender top)(min. 2mlat room temp) Prenatal Diagnosis Diagnostic Testing: Other: SUMF1 NEU1 LAMP2 GRN GALNS CTNS AGA SUMF1, TPP1 GUSB, HEXB, HEXA, HGSNAT, HYAL1, IDS,IDUA, LAMP2,LIPA, MAN2B1,MANBA, MCOLN1, MFSD8, NAGA, NAGLU, NEU1,NPC1,NPC2,PPT1, PSAP, SGSH,SLC17A5, SMPD1, AGA, ARSA, ARSB, ASAH1, CTSD, CTSA, CLN3,CLN5,CLN6,CLN8,CTNS, GALC, FUCA1,GAA, GNPTAB, GLB1,GM2A, DNAJC5, CTSK, GALNS,GBA, GLA, GNPTG, GNS,GRN, Lysosomal Storage Disorders (50) F5 -Factor (Mass VLeiden(F5:p.R534Q) Array) F2 -Prothrombin G20210A(F2:c.97G>A)(Mass Array) CFTR -Cystic Fibrosis -70mutation screen (Mass Array) -AmyloidosisTTR SPTLC1 -Hereditary Neuropathy Sensory SCN4A NOTCH3 -CADASIL MECP2 Syndrome -RETT GJB2 (CX26)/GJB6(CX30) ACADM OTC ARG CPS1,GLUD1,ARG, ASS1,CA5A, ASL, GLUL, NAGS, OTC, SLC25A2, SLC25A13, SLC25A15, SLC7A7 Urea Cycle Disorders Panel (13) Unaffected Affected ( ) YYYY/MM/DD - Paramyotonia Congenita -MediumChainAcylCoADehydrogenase (MCAD) (INCLUDES DELETION/DUPLICATION ANALYSIS) TPP1 NPC1 LIPA GUSB GBA CTSA ARSA SLC25A2 ASL (provide tissue source): tissue (provide (INCLUDES DELETION/DUPLICATION ANALYSIS) Mutation: (include copy of report): of copy (include -Recessive Deafness

(must specify lab): specify (must

NPC2 MAN2B1 HEXA GLA CTSD ARSB SLC25A13 ASS1

PPT1 MANBA HEXB GLB1 CTSK ASAH1 SLC25A15 CA5A

Referring Physician: INCOMPLETE REQUESTS WILLBEBANKED Patient Information: Request for Expedited Result: Test Requests:

AUTHORIZED SIGNATURE ISREQUIRED Telephone: Telephone: Address: E-mail address: Address: Name: Signature: Physician name(print): Medical intervention Medical intervention adjacent to theitem of interest. panelssub- orindividualgenes maybeselected usingthecheckbox Use attached menuto select panels orindividualgenes. Panels, CC report to: Sex: Address: Birthdate: Name: Health Card Number: PSAP MCOLN1 HGSNAT GM2A DNAJC5 CLN3 SLC7A7 CPS1 Pregnancy Patient Identifier: tissue contamination studies (fragment analysis) MCC/Identity testing -Maternal cell contamination/ HFE -Hemochromatosis p.C282Y andp.H63D(Mass Array) OTC CLN3 -Batten CLN2-TPP1 -Batten Disease CTNS ARSA NPC (NPC1/NPC2) -OrnithineTranscarbamylase aeFemale Male -Cystinosis -Metachromatic Leukodystrophy

: YY/MM/DD) (L.M.P., SGSH MFSD8 HYAL1 GNPTAB FUCA1 CLN5 GLUD1 (specify with date): with (specify Pathology and LaboratoryMedicine -Niemann-PickDisease Fax: Fax:

SLC17A5 NAGA IDS GNPTG GAA CLN6 GLUL NGSMGL(12/04/2017) (03/17/2021) SMPD1 NAGLU IDUA GNS GALC CLN8 NAGS