UNIVERSITY OF MINNESOTA PHYSICIANS OUTREACH LABS Submit this form along with the appropriate MOLECULAR DIAGNOSTICS (612) 273-8445 Molecular requisition (Molecular Diagnostics or DATE: TIME COLLECTED: PCU/CLINIC: Molecular NGS Oncology). 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 gene(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 Brugada syndrome DMD Aortopathy Full panel DNAJC19 SCN5A DSP Full panel GPD1L Cardiomyopathy, familial MYH11 CACNA1C hypertrophic ACTA2 SCN1B Full panel MYLK KCNE3 ANKRD1 FBN2 SCN3B JPH2 SLC2A10 HCN4 PRKAG2 COL5A2 MYH7 COL5A1 MYL2 COL3A1 Cardiomyopathy ACTC1 CBS Cardiomyopathy, dilated CSRP3 SMAD3 Full panel TNNC1 TGFBR1 LDB3 MYH6 TGFBR2 LMNA VCL FBN1 ACTN2 MYOZ2 Arrhythmogenic right ventricular DSG2 PLN dysplasia NEXN CALR3 TNNT2 TNNT2 NEXN Full panel RBM20 TPM1 TGFB3 SCN5A MYBPC3 DSG2 MYH6 TNNI3 DSC2 TNNI3 MYL3 JUP TTN TTN RYR2 BAG3 MYLK2 TMEM43 DES Cardiomyopathy, familial DSP CRYAB EYA4 restrictive PKP2 Full panel Atrial fibrillation LAMA4 MYPN TNNI3 SGCD MYPN TNNT2 Full panel CSRP3 SCN5A MYBPC3 GJA5 TCAP ABCC9 ABCC9 SCN1B PLN SCN2B ACTC1 KCNQ1 MYH7 KCNE2 TMPO NPPA VCL NPPA TPM1 KCNA5 TNNC1 KCNJ2 GATAD1 4/1/2014 Version 1 Heart block Congenital heart SCN5A Syndromes defects TRPM4 Alagille syndrome Left ventricular noncompaction JAG1 Aortic supravalvular stenosis TAZ Andersen syndrome ELN DTNA KCNJ2 Aortic valve disease MYBPC3 Barth syndrome NOTCH1 LDB3 TAZ SMAD6 ACTC1 Danon disease ASD with heterotaxy MYH7 LAMP2 CRELD1 TNNT2 Emery-Dreifuss muscular dystrophy Atrial septal defect 2 TPM1 EMD Full panel Lipid disease LMNA GATA4 LPL Fabry disease, cardiac variant MYH6 LDLR GLA TBX20 PCSK9 Holt-Oram syndrome ACTC1 LDLRAP1 TBX5 TLL1 ANGPTL3 Noonan syndrome NKX2-5 LMF1 Full panel CITED2 ABCA1 MAP2K1 Atrioventricular septal defect 2 Long QT syndrome MAP2K2 Full panel Full panel HRAS CRELD1 KCNE2 PTPN11 GJA1 SNTA1 KRAS GATA4 KCNJ5 SOS1 GATA6 KCNQ1 RAF1 Congenital heart defects SCN4B NRAS TAB2 AKAP9 BRAF Conotruncal heart malformations KCNH2 SHOC2 NKX2-5 SCN5A Sengers syndrome Hypoplastic left heart syndrome 1 ANK2 AGK Full panel KCNE1 Timothy syndrome GJA1 CAV3 CACNA1C NKX2-5 Pulmonary hypertension Persistent truncus arteriosus BMPR2 NKX2-6 SMAD9 Tetralogy of Fallot Short QT syndrome Ventricular fibrillation Full panel Full panel DPP6 TBX1 KCNH2 SCN5A NKX2-5 KCNQ1 CASQ2 Transposition of the great arteries, KCNJ2 RYR2 dextro-looped 1 Sick sinus syndrome CASQ2 MED13L Full panel CALM1 Ventricular septal defect SCN5A TRDN Full panel HCN4 Wolff-Parkinson-White syndrome GATA4 MYH6 PRKAG2 CITED2 4/1/2014 Version 1 .