UNIVERSITY OF MINNESOTA PHYSICIANS OUTREACH LABS Submit this form along with the appropriate Molecular requisition (Molecular Diagnostics or MOLECULAR DIAGNOSTICS (612) 273-8445 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 Ectodermal dysplasia epidermolysis bullosa simplex with Acne inversa muscular dystrophy Full panel PLEC Full panel EDA Epidermolytic hyperkeratosis NCSTN EDARADD Full panel PSENEN MSX1 KRT1 PSEN1 KRT85 KRT10 Acrodermatitis enteropathica PVRL4 Erythroderma, congenital, with NFKBIA palmoplantar keratoderma, SLC39A4 IKBKG hypotrichosis, and hyper IgE Amyloidosis, primary localized Ectodermal dysplasia/skin fragility DSG1 cutaneous, 1 syndrome Erythrokeratodermia variabilis with PKP1 erythema gyratum repens Full panel Ectrodactyly, ectodermal dysplasia, GJB4 OSMR and cleft lip/palate syndrome 3 Familial benign pemphigus IL31RA TP63 ATP2C1 Atrichia with papular lesions Focal facial dermal dysplasia 3 Focal dermal hypoplasia TWIST2 HR PORCN Epidermodysplasia verruciformis Autosomal recessive hypohidrotic Glomuvenous malformations Full panel ectodermal dysplasia syndrome GLMN TMC6 Griscelli syndrome EDAR TMC8 Full panel Buschke-Ollendorff syndrome Epidermolysis bullosa dystrophica RAB27A COL7A1 MYO5A LEMD3 Epidermolysis bullosa simplex Cleft lip/palate-ectodermal dysplasia MLPH Full panel syndrome Hyaline fibromatosis syndrome KRT14 ANTXR2 PVRL1 KRT5 Hyperpigmentation, Cole disease Epidermolysis bullosa, junctional, Herlitz type KITLG ENPP1 Full panel Hypotrichosis Corneal intraepithelial dyskeratosis LAMA3 Full panel and ectodermal dysplasia LAMB3 DSC3 LAMC2 LPAR6 COL17A1 APCDD1 NLRP1 Darier disease ITGB4 KRT74 ITGA6 DSG4 ATP2A2 DSP LIPH 4/1/2014 Version 1 Ichthyosis Palmoplantar keratoderma, epidermolytic Full panel KRT9 ABHD5 Papillon-Lefèvre syndrome CSTA CTSC KRT2 Peeling skin syndrome KRT1 CDSN SLC27A4 Peeling skin syndrome, acral type KRT10 TGM5 ST14 Pityriasis rubra pilaris TGM1 CARD14 PNPLA1 Poikiloderma with neutropenia ALOX12B USB1 ALOXE3 Porokeratosis, disseminated ABCA12 superficial actinic, 1 CYP4F22 SART3 NIPAL4 Psoriasis, generalized pustular LIPN IL36RN CLDN1 Pyogenic sterile arthritis, pyoderma STS gangrenosum, and acne SPINK5 PSTPIP1 Reticulate acropigmentation of LOR Kitamura Keratosis ADAM10 Full panel Seborrhea-like dermatitis with AQP5 psoriasiform elements MBTPS2 ZNF750 POMP Tylosis with esophageal cancer Kindler syndrome RHBDF2 FERMT1 UV-sensitive syndrome Lipid proteinosis / Urbach-Wiethe Full panel ECM1 ERCC6 Meleda disease ERCC8 SLURP1 UVSS3 Monilethrix Venous malformations, multiple cutaneous and mucosal Full panel TEK KRT81 White sponge nevus KRT83 KRT13 KRT86 KRT4 Olmsted syndrome Woolly hair, autosomal dominant TRPV3 KRT74 Odontoonychodermal dysplasia WNT10A Pachyonychia congenita Full panel KRT17 KRT6B KRT16 KRT6A 4/1/2014 Version 1 .