UNIVERSITY OF MINNESOTA PHYSICIANS OUTREACH LABS Submit this form along with the appropriate Molecular requisition (Molecular Diagnostics or MOLECULAR DIAGNOSTICS (612) 273-8445 Molecular NGS Oncology). DATE: TIME COLLECTED: PCU/CLINIC: AM PM PATIENT IDENTIFICATION DIAGNOSIS (Dx) / DIAGNOSIS CODES (ICD-9) - OUTPATIENTS ONLY SPECIMEN TYPE: o Blood (1) (2) (3) (4) PLEASE COLLECT 5-10CC IN ACD-A OR EDTA TUBE ORDERING PHYSICIAN NAME AND PHONE NUMBER: Tests can be ordered as a full panel, or by individual (s). Please contact the genetic counselor with any questions at 612-624-8948 or by pager at 612-899-3291. ______Test Ordered- EPIC: Next generation sequencing(Next Gen) Sunquest: NGS

CAKUT Familial hypomagnesemia Alport syndrome Full Panel Full Panel Full Panel BMP4 TRPM6 COL4A3 BMP7 CLDN16 COL4A4 CHD1L EGF COL4A5 EYA1 CLDN19 APRT deficiency GATA3 CNNM2 APRT HNF1B FXYD2 Arthrogryposis, renal dysfunction, and PAX2 Gitleman syndrome cholestasis RET SLC12A3 Full Panel ROBO2 Fanconi renotubular syndrome VPS33B SALL1 SLC34A1 VIPAS39 SIX1 Fanconi-Bickel syndrome Bardet Biedl syndrome SIX2 Full Panel SIX5 SLC2A2 BBS1 SOX17 FSGS / Nephrotic syndrome BBS10 UMOD TRIM32 UPK3A Full Panel BBS12 Complement nephropathy WT1 MKS1 Full Panel ACTN4 CEP290 CFHR1 TRPC6 WDPCP CFHR3 CD2AP SDCCAG8 CFHR4 APOL1 BBS2 CFH INF2 ARL6 CD46 MYO1E BBS4 CFI NXF5 BBS5 CFB ITGA3 MKKS THBD LMX1B BBS7 CFHR5 ACTN4 TTC8 C1QA CD2AP BBS9 C1QB MYO1E Bartter syndrome C1QC NEIL1 Full Panel C3 NPHS1 SLC12A1 THBD NPHS2 KCNJ1 Cystinosis PLCE1 CLCNKB Full Panel WT1 BSND CTNS LAMB2 CLCNKA SLC3A1 PTPRO Branchio-oto-renal syndrome SLC7A9 Glomerulopathy with fibronectin Dent syndrome deposits 2 Full Panel Full Panel SIX1 CLCN5 FN1 EYA1 OCRL Hypercalciuria SIX5 ADCY10 4/1/2014 Version 1 Hyperoxaluria Polycystic kidney disease UMOD related kidney disorders Full Panel Full Panel UMOD AGXT PKD1 Vesicoureteral reflux GRHPR PKD2 Full Panel Hypomagnesemia and Renal Magnesium PKHD1 ROBO2 Wasting. Renal adysplasia SOX17 PCBD1 UPK3A

Infantile hypercalcemia Renal amyloidosis CYP24A1 LYZ Renal coloboma syndrome Full Panel PAX2 TCTN2 Renal cysts and diabetes syndrome INPP5E HNF1B OFD1 Renal dysplasia KIF7 Full Panel TCTN1 BICC1 TMEM237 AGT CEP41 AGTR1 TMEM138 Renal glucosuria C5orf42 SLC5A2 TMEM216 Renal hypouricemia NPHP1 Full Panel CEP290 SLC22A12 TMEM67 SLC2A9 TTC21B Renal tubular acidosis RPGRIP1L Full Panel ARL13B CA2 CC2D2A ATP6V1B1 AHI1 SLC4A1 Liddle syndrome ATP6V0A4 Full Panel SLC4A4 SCNN1B Renal tubular dysgenesis SCNN1G ACE Medullary cystic kidney disease Rickets UMOD Full Panel Nephrogenic diabetes insipidous SLC34A3 Full Panel DMP1 AQP2 FGF23 AVPR2 ENPP1 Nephrolithiasis/osteoporosis PHEX SLC9A3R1 VDR CYP2R1 Full Panel CYP27B1 NPHP1 Schimke immunoosseous dysplasia SDCCAG8 SMARCAL1 TMEM67 Senior Loken Syndrome TTC21B Full Panel WDR19 NPHP1 INVS NPHP4 NPHP3 IQCB1 NPHP4 CEP290 IQCB1 SDCCAG8 CEP290 Townes-Brocks syndrome GLIS2 SALL1 RPGRIP1L Tumoral calcinosis NEK8 XPNPEP3 KL

4/1/2014 Version 1