Requisition for DNA Testing Requisition for DNA Testing Reason for Referral: Patient Information: LAB USE ONLY PATIENT INFORMATION (INCOMPLETE REQUESTS WILL BE BANKED) INCOMPLETE REQUESTS WILL BE BANKED Diagnostic Testing: ReceivedAffected date: Name: Name: Unaffected Address: Notes:Carrier testing/Known Family Mutation Birthdate: Name of index case in the family (include copy of report): DateAddress: of Birth: YYYY/MM/DD Date of Birth: HealthSex: CardMale No.: Female Relationship to this patient: REASON FOR REFERRAL Sex:Health M Card Number: F Other Gene: Mutation: RefSeq:NM: Diagnostic Testing: TestTEST Requests:REQUESTS Prenatal Affected Diagnosis Use attached menu to select panels or individual genes. DNA Banking Unaffected Use attached menu to select panels or individual genes. Panels, RNA Carrier Banking testing/Known Family Mutation sub-Panels, panels sub-panels or individual or genesindividual may begenes selected may using be selected the checkbox adjacentusing the to checkboxthe item of adjacentinterest. to the item of interest. LHSCReferral MD#/Name to an outside of Index laboratory case in the (must family specify (include lab): copy of report): London Health Sciences Centre – Molecular Diagnostics Centre Sciences Health London London Health Sciences Centre – (Molecular Genetics) London Health Sciences Centre SampleDate of Collection:Birth: REQUEST FOR EXPEDITED RESULT Relationship to this patient: Date drawn: (YYYY/MM/DD) Request for Expedited Result: Gene:EDTA blood (lavender top)(min.RefSeq:NM: 2ml at room temp) Pregnancy (L.M.P., YYYY/MM/DD): EDTA bone marrow (lavender top)(min. 2ml at room temp) PregnancyMedical Intervention (L.M.P., YY/MM/DD) (specify: with date): Mutation:DNA (100ng to 1ug): ug Medical intervention (specify with date): Fresh/Frozen Tissue (provide tissue source): Formalin Prenatal fixed Diagnosis paraffin embeddedDNA Banking tissue (FFPE) RNA Banking (slides Referral preferred) to an outside laboratory (must specify lab): Other: REFERRING PHYSICIAN Authorized Signature is Required ClinicalSAMPLE Diagnostics COLLECTION and Family History: AUTHORIZED SIGNATURE IS REQUIRED ReferringPhysician Name Physician: (print): Date drawn (YYYY/MM/DD): Signature: Email: EDTA blood (lavender top)(min. 2ml at room temp) Physician name (print): EDTA bone marrow (lavender top)(min. 2ml at room temp) Signature:Clinic/Hospital: DNA (100ng to 1ug): ug Address:Address: Lab UseFresh/Frozen Only: Tissue (provide tissue source): Formalin fixed paraffin embedded tissue (FFPE - slides preferred) Telephone:Telephone: Fax: Fax: ReceivedOther: date: E-mailCC report address: to: CC report to: CLINICALNotes: INFORMATION AND FAMILY HISTORY Name: Name: Address: Address: Telephone:Telephone: Fax: Fax: MOLECULARMolecular GeneticsGENETICS Laboratory LABORATORY VictoriaVictoria Hospital, Hospital, Room RoomB10-123A B10-123A 800800 Commissioners Commissioners Rd E. Rd. E. London,London, Ontario Ontario | N6A | 5W9 N6A 5W9 Pathology and Laboratory Medicine Page 1 of 3 Page Ph: 519-685-8122 | Fax: 519-685-8279 (05/11/2021) Page 1 of 5 1 of Page Ph: 519-685-8122 | Fax: 519-685-8279 NGSMGL(12/04/2017) Requisition for DNA Testing Requisition for DNA Testing Patient Identifier: Reason for Referral: Please use the dedicated requisitions for the followingPatient test requests: Information: INCOMPLETE REQUESTS WILL BE BANKED - HereditaryDiagnostic Cancer Testing: Panel (HCP) - EpilepsyAffected Name: - AtypicalUnaffected Hemolytic Uremic Syndrome - HematologicCarrier testing/Known Oncology Family Mutation Birthdate: - NameBiochemical of index Genetics case in the family (include copy of report): Requisitions can be found at https://www.lhsc.on.ca/palm/forms/requisitions.html#moldxAddress: SampleDate of RequirementsBirth: can be found at https://www.lhsc.on.ca/palm/molecular/specimen.html#main-contentSex: Male Female Relationship to this patient: Health Card Number: NGSGene: PANELS (INCLUDES DELETION/DUPLICATIONMutation: ANALYSIS) RefSeq:NM: Charcot Marie Tooth Test Requests: Prenatal Diagnosis Charcot Marie Tooth, HNPP - Comprehensive (34) DNAAARS, Banking AIFM1, DNAJB2, DYNC1H1, EGR2, FGD4, FIG4, GARS, GDAP1, GJB1, HSPB1, HSPB8,Use IGHMBP2, attached KIF1B, menu LITAF, LMNA, to select LRSAM1, panels MARS, or MED25,individual MFN2, genes. MPZ, MTMR2, Panels, RNANDRG1, Banking NEFL, PDK3, PMP22, PRPS1, PRX, RAB7A, SBF2, SH3TC2, SPTLC1, TRPV4, TTR sub- panels or individual genes may be selected using the checkbox Referral to an outside laboratory (must specify lab): adjacent to the item of interest. Charcot Marie Tooth - Individual selections (Individual selections available for out-of-province requests only except SPTLC1 and TTR) AARS AIFM1 DNAJB2 DYNC1H1 EGR2 FGD4 FIG4 GARS London Health Sciences Centre – Molecular Diagnostics Centre Sciences Health London London Health Sciences Centre – (Molecular Genetics) London Health Sciences Centre GDAP1 GJB1 HSPB1 HSPB8 IGHMBP2 KIF1B LITAF LMNA SampleLRSAM1 Collection:MARS MED25 MFN2 MPZ MTMR2 NDRG1 NEFL PDK3 PMP22 PRPS1 PRX RAB7A SBF2 SH3TC2 SPTLC1 (YYYY/MM/DD) Date drawn:TRPV4 TTR Request for Expedited Result: EDTA blood (lavender top)(min. 2ml at room temp) MitochondrialEDTA bone marrow Genome (lavender and top)(min. Depletion/Integrity 2ml at room temp) Panel Pregnancy (L.M.P., YY/MM/DD): DNA (100ng to 1ug): ug Mitochondrial Genome and Depletion/Integrity Panel (56) Medical intervention (specify with date): Fresh/Frozen Tissue (provide tissue source): Mitochondrial encoded genes: ATP6, ATP8, COX1, COX2, COX3, CYTB, ND1, ND2, ND3, ND4, ND4L, ND5, ND6, RNR1, RNR2, TRNA, TRNC, TRND, TRNE, TRNF, TRNG, TRNH, FormalinTRNI, TRNK, fixed TRNL1, paraffin TRNL2, TRNM, embedded TRNN, TRNP, tissue TRNQ, TRNR,(FFPE) TRNS, TRNS2, TRNT, TRNV, TRNW, TRNY (slides preferred) Nuclear encoded genes: APTX, DGUOK, DNA2, FBXL4, GFER, MGME1, MPV17, OPA1, OPA3 (isoform A & B), POLG, POLG2, RRM2B, SLC25A4, SPG7 (isoform 1 & 2), SUCLA2, Other:SUCLG1, TK2, TWNK, TYMP Mitochondrial Genome and Depletion and Integrity - Individual selections (Individual selections available for out-of-province requests only) ClinicalMitochondrial Diagnostics encoded genes: and Family History: AUTHORIZED SIGNATURE IS REQUIRED ATP6 ATP8 COX1 COX2 ReferringCOX3 Physician:CYTB ND1 ND2 ND3 ND4 ND4L ND5 ND6 RNR1 RNR2 TRNA TRNC TRND TRNE TRNF PhysicianTRNG name (print):TRNH TRNI TRNK TRNL1 TRNL2 TRNM TRNN Signature:TRNP TRNQ TRNR TRNS TRNS2 TRNT TRNV TRNW TRNY Address: LabNuclear Use encoded Only: genes: Telephone: Fax: APTX DGUOK DNA2 FBXL4 GFER MGME1 MPV17 OPA1 Received date: OPA3 (isoform A & B) POLG POLG2 RRM2B E-mailSLC25A4 address: SPG7 (isoform A & B) SUCLA2 SUCLG1 TK2 TWNK (C10 or f2) TYMP Notes: CC report to: Name: Address: Telephone: Fax: MOLECULARMolecular GeneticsGENETICS Laboratory LABORATORY VictoriaVictoria Hospital, Hospital, Room RoomB10-123A B10-123A 800800 Commissioners Commissioners Rd E. Rd. E. London,London, Ontario Ontario | N6A | 5W9 N6A 5W9 Pathology and Laboratory Medicine Page 2 of 3 Page Ph: 519-685-8122 | Fax: 519-685-8279 Page 1 of 5 1 of Page Ph: 519-685-8122 | Fax: 519-685-8279 NGSMGL(12/04/2017)(05/11/2021) Requisition for DNA Testing Requisition for DNA Testing Patient Identifier: Reason for Referral: Patient Information: Lysosomal Storage Disorders INCOMPLETE REQUESTS WILL BE BANKED Diagnostic Testing: LysosomalAffected Storage Disorders (50) Name: AGA,Unaffected ARSA, ARSB, ASAH1, CLN3, CLN5, CLN6, CLN8, CTNS, CTSA, CTSD, CTSK, DNAJC5, FUCA1, GAA, GALC, GALNS, GBA, GLA, GLB1, GM2A, GNPTAB, GNPTG, GNS, GRN, CarrierGUSB, HEXA,testing/Known HEXB, HGSNAT, HYAL1,Family IDS, Mutation IDUA, LAMP2, LIPA, MAN2B1, MANBA, MCOLN1, MFSD8, NAGA, NAGLU, NEU1, NPC1, NPC2, PPT1, PSAP, SGSH, SLC17A5, SMPD1, SUMF1, TPP1 Birthdate: Name of index case in the family (include copy of report): Lysosomal Storage Disorders - Individual selections Address: Date ofAGA Birth: ARSA ARSB ASAH1 Sex:CLN3 Male FemaleCLN5 CLN6 CLN8 RelationshipCTNS to this patient:CTSA CTSD CTSK DNAJC5 FUCA1 GAA GALC Health Card Number: Gene:GALNS GBA Mutation:GLA GLB1 GM2A GNPTAB GNPTG GNS GRN GUSB HEXA HEXB HGSNAT HYAL1 IDS IDUA RefSeq:NM: LAMP2 LIPA MAN2B1 MANBA TestMCOLN1 Requests: MFSD8 NAGA NAGLU PrenatalNEU1 DiagnosisNPC1 NPC2 PPT1 PSAP SGSH SLC17A5 SMPD1 DNASUMF1 Banking TPP1 Use attached menu to select panels or individual genes. Panels, RNA Banking sub- panels or individual genes may be selected using the checkbox UreaReferral Cycle to an Disorders outside laboratory (must specify lab): adjacent to the item of interest. Urea Cycle Disorders Panel (13) London Health Sciences Centre – Molecular Diagnostics Centre Sciences Health London AGR1, ASL, ASS1, CA5A, CPS1, GLUD1, GLUL, NAGS, OTC, SLC25A2, SLC25A13, SLC25A15, SLC7A7 London Health Sciences Centre – (Molecular Genetics) London Health Sciences Centre SampleUrea Cycle Collection: Disorders - Individual selections NGS PANELSARG1 (INCLUDESASL DELETION/DUPLICATIONASS1 ANALYSIS) CA5A CPS1 GLUD1 GLUL NAGS Date drawn: (YYYY/MM/DD) Request for Expedited Result: OTC SLC25A2 SLC25A13 SLC25A15 SLC7A7 EDTA blood (lavender top)(min. 2ml at room temp) EDTA bone marrow (lavender top)(min. 2ml at room temp) Pregnancy (L.M.P., YY/MM/DD): SINGLEDNA (100ngGENES to BY1ug): NGS (INCLUDES ug DELETION/DUPLICATION ANALYSIS) Medical intervention (specify with date): Fresh/Frozen Tissue (provide tissue source): FormalinACADM fixed - Medium paraffin Chain embedded Acyl CoA tissue Dehydrogenase (FFPE) (MCAD) NPC (NPC1/NPC2) - Niemann-Pick Disease (slides preferred) GJB2 (CX26) / GJB6 (CX30) - Recessive Deafness ARG1 - Arginase