Molecular Diagnostic Laboratory 1600 Rockland Road, Wilmington, DE 19803 302.651.6775 email: [email protected] CLIA #08D0706140 Next Generation Sequencing (NGS) Panel Sample Submission Patient Information Patient Name (Last, First): Biologic sex: Male Female Other or Unknown Date of Birth (MM/DD/YYYY): Medical Record Number: Collection date (MM/DD/YYYY): Sample Type: Blood DNA Buccal swab Other (Specify): Ordering Physician (required) Additional report recipient (genetic counselor, send-out lab, etc.) Name: Name: Address: Address: Phone: Fax: Phone: Fax: e-mail: e-mail: Billing Information (required) Please note: We do not bill third party payers (insurance companies). The person or Patient Bill Amount: $______________ institution sending the sample is responsible for full payment of the invoice. If paying by credit card, please complete additional information Please bill my credit card for the full amount stated above Signature of Card holder (required) Institutional Billing Include a billing contact at your institution, and an MasterCard Visa American Express Discover email to send the invoice. Institution Name of Card holder Contact name Credit Card Number Email Fax: Phone: Expiration Date Security Code Street Patient Billing Address: City/State/Zip Code City/State/Zip Code Phone Clinical Information- Clinical information is required for interpretation purposes; please attach additional clinic notes if appropriate. Brief description: Testing Requested Renal Disease Nephrotic syndrome and related disorders panel ACTN4; ALG1; ALMS1; APOL1; ARHGAP24; ARHGDIA; CD151; CD2AP; CFH; COL4A3; COL4A4; COL4A5; COQ2; COQ6; COQ7; COQ8 (ADCK4); COQ9; CRB2; CUBN; CYP11B2; CYP24A1; DGKE; E2F3; EMP2; FAM161B; INF2; ITGA3; ITGB4; KANK2; LAMB2; LMX1B; MED28; MEFV; MYH9; MYO1E; NEIL1; NPHS1; NPHS2; PDSS2; PLCE1; PMM2; PTPRO; SCARB2; SMARCAL1; TRPC6; WT1; ZMPSTE24 Prior genetic testing results (if completed at an outside lab please attach report): BAF-Related Disorders Family history (if familial mutation is known, please specify; and BAF-related disorders panel include pedigree if available): ACTL6A; ARID1A; ARID1B; ARID2; DPF2; PHF6; SMARCA2; SMARCA4; SMARCB1; SMARCE1; SOX11 Leukodystrophies Leukodystrophy related disorders panel AARS1; AARS2; DARS1; DARS2; EARS2; FAM126A; GJC2; HEPACAM; LMNB1; MARS2;MLC1; PLP1; POLR1C;POLR3A; POLR3B; RARS1; SLC16A2; TUBB4A July 2019 .