hereditary test requisition fast processing prenatal ... · blood-adult(2 x 4ml edta) 4005 acg ......

HEREDITARY TEST REQUISITIONAppointment Booking: www.lifelabs.com

1-844-363-4357· [email protected]

2020 v9 Page 1/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential. Unauthorized use and disclosure are prohibited.

CONTRACT # LL: K012-01

Report to Physician #Physician OHIP# (Ontario) or CPSO#: Physician MSC# (British Columbia): Other Provinces: 999

Ordering Physician Name

Ordering Physician Address & contact info: Tel:

Unit Number: Street Number: Street Name: City/Town: Province: Postal Code:

PO Box:

Fax: e-mail:

Physician Signature:

Confirmation of Patient Consent: I confirm that this patient has given consent to testing as may be required by applicable law, which indicates that: the patient has been informed about the details associated with the genetic test(s) ordered below including its risks, benefits and limitations; I/we will ensure that test results will be interpreted to the patient in an appropriate manner, and that the patient will not receive the results without accompanying counseling; and the patient was informed that s/he has the right to revoke his/her consent at any time

X_______________________________________________________________

Copy to: Genetic Counsellor Other Healthcare Provider Tel: Fax: e-mail:

Bill to: Contract # K012-01 (patient does not pay at time of collection) Patient Sex: Female Male

Patient Name (Last, First): Patient DOB:YYYY/MM/DD

Patient Address:Patient Tel:

Patient Information:

African/African American Caucasian French Canadian or AcadianMiddle Eastern Northern European e.g. British, German South Asian e.g. Indian, Pakistani East Asian e.g. Chinese, Japanese

Ashkenazi Jewish Other/Mixed Caucasian Native American Hispanic Southern European e.g. Italian, Greek Southeast Asian e.g. Filipino, Vietnamese Pacific Islander

Relevant Medical and Family History

No additional information Previous testing in family (patient name/ID):

Billing Status Ministry of Health Approved (Approval letter attached) Ministry of Health Approval Pending Institution (Complete information below) Private Pay (Complete additional form)

Institution BillingONLY

Institution Name: ___________________________________ Contact Name: _____________________________Address:

Phone: ( ) - Fax: ( ) - Email: _______________________________

For samples not collected at a LifeLabs location, please ship all NON-PRENATAL samples to: LifeLabs • Attn. Specimen Management • 3680 Gilmore Way • Burnaby BC • V5G 4V8

Ordering Checklist Sample Type

Known variant

Single gene

Must complete pages 1, 2, & 3 LL TC Mnemonic Blood-Adult (2 x 4ml EDTA) 4005 ACG Blood-Pediatric (1 x 2ml EDTA) 4008 CEN

Fx Panels

Ex Panel

ProGx Panels

Must complete pages 1-5

Clinical features checklist (p5)

Physician, patient, & test information (p1-2)Informed consent (p3)

Physician, patient, & test information (p1-2)Informed consent (p3-4)

Physician, patient, & test information (p1-2)Informed consent (p3-4)

Purified DNA (No CNV analyses)(Single genes: 1-10µg, Panels: >10µg)

4014 OCG

Filter card* Other:** _________

4014 4014

OCG OCG

Whole Exome Sequencing (WES)

Whole GenomeSequencing (WGS)

Must complete pages 1-8 (if applicable)

Clinical features checklist (p5)Parental 1 & 2 requisitions (p6-7)(if Trio selected) Additional Family Member requisition (p8)(if TrioPlus selected OR Parental samples unavailable)

* Available by request. Please contact LifeLabs Genetics.** Other sample types are permitted. Please contact LifeLabs

Genetics for details.

Please contact LifeLabs Genetics before shipping prenatal samples. Samples should be shipped directly to Centogene.

Date Sample Collected: Time Collected: Collector Name:

LifeLabs Demographic Label

Additional Label (if needed)

_______________ _____________________

Health Card #: Unit Number: Street Number: Street Name: City/Town: Province: Postal Code:

PO Box:

Last: First:

Last: First:

please contact 1-844-363-4357 or [email protected]

! For Fast Processing or Prenatal Processing,

REQUISITION **PHOTOCOPY REQUISITION AND INCLUDE 1 COPY WITH SAMPLES**


Patient Name: Patient DOB (YYYY/MM/DD):

September 2019_v8 Page 2/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential. Unauthorized use and disclosure are prohibited.

Testing for known variants

Gene: _______________________________ Mutation (HGVS) :______________________

Please attach a copy of the familial report (testing may be delayed without it)

Testing for

Single Gene(s) or Fixed Panel(s)

Please use the online catalogue to find test code & names www.lifelabsgenetics.com/hereditary-conditions Test Code(s): ______________________________________________________________

Test Name(s): _____________________________________________________________________________________________

Single Genes *Sequencing and CNV (by NGS) **Sequencing (by NGS or Sanger Sequencing) Deletion/Duplication Testing Only (by MLPA or qPCR) Repeat Expansion Testing

Fixed Panels ***Sequencing and CNV (repeat expansion included, if applicable) Deletion/Duplication Testing Only (by MLPA or qPCR)

*Depending on coverage optimization, sequencing may be performed via Sanger.**For select genes, only Sanger Sequencing is available. CNV or deletion/duplication testing by MLPA or qPCR may not be available.***For Select panels, only Sequencing is available (ex: Mitochondrial DNA sequencing, Metabolic Disease Panel, and Ashkenazi Jewish Carrier Testing).

Expanded Panel

Please contact LifeLabs Genetics if you require a Reference Number for your request

Ex Panel Sequencing + CNV (CN50088) >98% of targeted bases covered at >20x70-100x average read depth

Test Code: __________________________________________________________________

Test Name(s): __________________________________________________________________________________________________

Research Report (Includes potential disease-causing variants in candidate genes for which there is not yet sufficient published evidence)

Progressive Panels

Please contact LifeLabs Genetics to receive a Reference Number for your request

ProGx Panels (by NGS Panel Genomic)(Reflex available – Please contact us)

30x average read depth ~99% of targeted bases covered at >10x Deletion/Duplication is included Repeat expansion is available as an add-on and should be requested when obtaining a Reference Number

Reference Number: ______________________________________________

Whole Exome Sequencing (WES)

70-100x average read depth >98% of targeted bases covered >20X Turnaround time is 4-6 weeks

Number of samples select ONE of the following options:

SoloSolo implies analysis of index patient only; we recommend Trio analysis for enhanced diagnostic accuracy.

TrioTrio implies analysis of index patient, along with the parents.

Trio Plus“Trio plus” indicates “Trio” plus additional relatives. All Trio samples have to be received simultaneously to start testing. If not, each sample from the same family will be charged as a solo.

Reporting and data exchange .fastq .bam .vcfRaw data (.fastq and .bam files) are available only for a limited time and must be downloaded from the server within 1 month after the customer is informed of the completion of the analysis or after the final medical report has been issued. Data selected above with annotated and

filtered variant report (Excel table)

Research Report (Includes potential disease-causing variants in candidate genes for which there is not yet sufficient published evidence)

Whole Genome Sequencing (WGS) WGS

30x average read depth ~99% of targeted bases covered at >10x Turn-around time is 4-6 weeks Prenatal testing is available CNV included

Additional information or instructions

Eg: Specify genes of interest for Custom Fx or ProGx panels

WES + CNV

WES + mtDNA

WES + CNV + mtDNA

mailto:[email protected]





INFORMED CONSENT (ALL)(For Ex and ProGx Panels, Whole Exome, and Whole Genome analyses, please also signed consent on page 4.)

GENETIC TESTING CONSENT A genetic test studies the inherited substance (DNA) using a molecular-genetic analysis of characteristics, which may be the cause of the disease that has occurred or is suspected in you or your family. The study material is usually a blood sample. Normally there are no health risks when taking a blood sample. Sometimes patients can experience bruising (hematoma) at the drawing site or, very rarely, there could be nerve damage. Another risk that cannot be fully excluded exists in the extremely unlikely possibility of the samples being swapped. Every effort is made to avoid this and other mistakes.

Test Results and Reporting DNA sequencing analyzes your DNA and compares it to the reference human genome. Variations (changes) are identified by comparing data with medical databases and looking for scientific links, all of which will be reported to your physician. While there are always certain variations, depending on the individual being tested and the available data, CENTOGENE and/or LifeLabs Genetics adhere to the guidelines set out by the American College of Medical Genetics (ACMG). A medical report may include information that is considered to be of direct and immediate relevance, either to your own health or to that of family members who share part of your genetic background. Possible results of genetic testing include:

• Positive: Indicates a genetic variant was identified in a specific gene and that variant is pathogenic of likely pathogenic (highly likely to be causal of thedisease-related condition).

• Negative: If no disease-causing variant is found, genetic changes responsible for the disease or a tendency to have a disease may still exist and cannot usually be fully excluded.

• Variant of Uncertain Significance: Sometimes, gene variants are proven but their significance is not clear. This is stated in the results and discussed with you byyour physician. This category of variant is not reported for fetal samples or samples from deceased persons.

In addition, CENTOGENE and LifeLabs Genetics also make use of its own mutation database (CentoMD®), which encompasses over 12,000 mutations collected from a global population. Our medical colleagues may recognize other genes that might be of medical significance, and these can be reported as well. Should you not wish to receive this information in your report, it is possible to opt out of this service. A comprehensive explanation of all possible causes of diseases due to genetic reasons is not possible. It is also not possible to exclude every disease risk for you and your family members, especially your children, utilizing genetic analyses.

I consent to the carrying out of the genetic analysis indicated on these pages, on me or the person I am custodian for.

I understand my specimen for DNA analysis will be sent to LifeLabs for genetic testing (7455 130th St., Surrey, BC, V3W 1H8 or 175 Galaxy Blvd. Toronto, ON, M9W 0C9). I am aware that correct information about the relationships between my family members is important. I agree that my specimen and personal health information may be sent to Centogene AG for genetic testing (Am Strande 7, 18055 Rostock, Germany). Your personal data, medical results, and sample are subject to medical confidentiality, and can only be disclosed with your written consent, other than as permitted or required by law. To ensure accurate testing, I agree that the results of genetic testing that I have had previously completed by Centogene AG may be shared with LifeLabs. I understand that LifeLabs will contact me for a new specimen, if a test result cannot be provided from the original specimen. I agree that a copy of my results will be sent to my ordering physician. I further agree that for any test(s) performed by Centogene AG, a copy of my results will also be sent to LifeLabs. I have been comprehensively informed by my physician of the medical and psychological consequences of genetic testing. I also confirm that I will receive genetic counselling to help me understand the impact and consequences of my diagnostic results.

1. I understand that, once the requested test(s) has/have been completed, personal data and remaining sample will be stored at the testing laboratory for 20 years. 2. I agree that my de-identified sample may be used for product development or research purposes. I understand that I will not receive any royalties, resultant

payments, benefits, or rights to products or discoveries.3. I consent to the storage and use of my pseudonymized (encrypted) or de-identified test results in a statistical database for scientific purposes and to facilitate and

improve the diagnosis of genetic changes and diseases in other patients. 4. I consent that my de-identified results stored in the database are being provided to physicians, scientists and researchers for the purposes of for researching

genetic diseases and improving their diagnostics and treatment.

I do not want my remaining sample or data from my results to be stored and/or used for product development or research purposes. Please destroy any remaining sample once the final report has been issued. By ticking this box I disagree with points 1, 2, 3, & 4 listed above.

You can withdraw your consent to the analysis at any time in full or in part without stating reasons. You have the right not to be informed about test results (right not to know), to stop the testing processes that have been started at any time up to being given the results and to request the destruction of all test material and all results collected up to that time.

Patient/Substitute Decision Maker: Signature: ________________________________________________; Date: ______________________________________

Printed name: ________________________________________________; Relationship to person being tested: __________________________________________

OR: I certify that verbal consent was obtained from the patient /substitute decision maker for the requested genetic testing

Signature of Physician: ___________________________________________________; Date: _____________________________________




Patient Name: Patient DOB (MM/DD/YYYY):


INFORMED CONSENT (Ex and ProGx Panels and Whole Exome and Whole Genome)

(In addition to the general informed consent on page 3)

Ex Panel and Whole Exome Sequencing The exome is the collection of the DNA sequences of the genes that determine the production of proteins, which your body needs in order to function properly. So far, the exome is where the vast majority of causative mutations have been identified by scientific research. Whereas most genetic tests focus on a single gene or a set number of predetermined genes, the exome examines >20,000 genes simultaneously.

ProGx Panels and Whole Genome Sequencing Our DNA is composed of exons (studied by sequencing the exome) and introns, among other regions. Introns were previously not considered to contain important genetic information, as these regions do not directly determine the function of proteins. Recent research has provided evidence that some of these regions may be involved in the development of certain rare diseases and disorders. Whole Genome Sequencing analyzes all parts of the >20,000 genes that make up our genome.

Incidental or Secondary Findings CENTOGENE and LifeLabs Genetics adhere to the guidelines set out by the American College of Medical Genetics (ACMG), which allow for reporting specific types of medically actionable or incidental findings (PMIDs: 23788249 and 25356965). Medically actionable findings may be associated to a predisposition to increased cancer risk, a carrier status of recessive diseases, or a predisposition to late-onset diseases, among others. This list of genes from the ACMG is constantly being updated to include all such instances of mutations that are seen as being relevant to patients. Patients are required to select whether or not they would like to receive information on the 59 genes or classes of genes outlined in these recommendations, which are known to be medically actionable. Incidental findings are not reported for fetal samples or samples from deceased persons.

Confirmation of Findings CENTOGENE and/or LifeLabs Genetics use Sanger sequencing to confirm all pathogenic variants that do not pass the quality control parameters of next-generation sequencing. Structural variants are confirmed by orthogonal methods, such as MLPA or qPCR.

Use of Parental Samples for Large Scale Testing Biological parental samples are used to improve the interpretation of the final results in exome and genome testing. In Trio analysis, testing and bioinformatic analyses on parental samples are done in parallel to the analysis of the index patient. We check the parents’ materials only with regard to the patient´s condition and issue parental reports accordingly. If additional analyses on the parental samples are required, such as complete exome analyses or analyses of the 59 genes or classes of genes outlined in the ACMG guidelines), please contact us as additional charges may apply. If several family members are tested, accurate interpretation of the results depends on the assumed relationships being correct. If doubt is created by the genetic analysis about the apparent relationships, we will not inform you. An exception will be made if it is absolutely necessary for the completion of the requested test.

Technical Limitations 1. Exome testing does not analyze all genes in the human genome. Some genes cannot be examined because of various technical reasons. Less than 2% of the

targeted exons may not be well covered due to various technical reasons. 2. You may have a mutation in one of the genes included in the test, but it is not always possible to detect all mutations with these methods. This means that a

patient can be affected with a certain condition, but that this testing does not identify or reveal it.3. Exome and Genome testing encompasses many different genes and looks for a variety of conditions and diseases. These tests may reveal genetic

information about you or a family member that is new and is not necessarily related to your reasons for ordering such a test. Such information could reveal details about diseases that will only develop in the future or for which there is no known treatment or cure.

Consent to Exome or Genome Testing (It is mandatory to ensure that a patient has signed his or her consent to conduct these genetic analyses)

________ The initials of the physician confirm the patient has been informed of all the information on this page. HCP

________ The initials of the patient confirm he/she has chosen to receive information on the 59 genes or classes of genes outlined in the ACMG Patient recommendations described above

_______ For private pay testing, the initials of the patient confirm, if an exome or genome test is cancelled prior to test set-up, he/she will be Patient charged a processing fee and will receive a cancellation report. Once testing is initiated, the full price of the analysis will be charged.






A. NEUROLOGY1. Behavioral abnormality

1.1 Autism 1.2 Attention deficit disorder

1.3 Psychiatric diseases 2. Brain imaging

2.1 Abnormal cortical gyration

2.2 Abnormal myelination

2.3 Agenesis of corpus callosum

2.4 Brain atrophy

2.5 Cerebellar hypoplasia

2.6 Heterotopia

2.7 Holoprosencephaly 2.8 Hydrocephalus 2.9 Leukodystrophy 2.10 Lissencephaly

3. Developmental delay

3.1 Delayed language dev.

3.2 Delayed motor dev.

3.3 Developmental regression

3.4 Intellectual disability 4. Movement abnormality

4.1 Ataxia

4.2 Chorea

4.3 Dystonia

4.4 Parkinsonism 5. Neuromuscular abnormality

5.1 Hyperreflexia

5.2 Muscle hypertonia

5.3 Muscle hypotonia

5.4 Spasticity 6. Seizures

6.1 Febrile seizures

6.2 Focal seizures

6.3 Generalized seizures 7. Others

7.1 Craniosynostosis

7.2 Dementia

7.3 Encephalopathy

7.4 Headache

7.5 Macrocephaly

7.6 Microcephaly 7.7 Migraine 7.8 Stroke

B. METABOLISM1. Abnormal creatine kinase 2. Decreased plasma carnitine 3. Hyperalaninemia 4. Hypoglycemia 5. Increased CSF lactate 6. Increased serum pyruvate 7. Ketosis8. Lactic acidosis9. Organic aciduria

C. EYE1. Blepharospasm2. Cataract3. Coloboma 4. Glaucoma 5. Microphthalmos 6. Nystagmus 7. Ophthalmoplegia 8. Optic atrophy9. Ptosis10. Retinitis pigmentosa11. Retinoblastoma12. Strabismus 13. Visual impairment

D. MOUTH, THROAT AND EAR1. Abnormality of dental color 2. Cleft lip / palate 3. Conductive hearing impair.4. External ear malformation 5. Hypodontia6. Sensoneural hearing impair.

E. SKIN, INTEGUMENT ANDSKELETAL

1. Skeletal 1.1 Abnormal limb morphology 1.2 Abnormal vertebral column 1.3 Abnorm. of the skeletal system 1.4 Joint hypermobility 1.5 Multiple joint contractures 1.6 Polydactyly 1.7 Scoliosis 1.8 Syndactyly 1.9 Talipes equinovarus

2. Skin and integument2.1 Abnormal hair 2.2 Abnormal nail 2.3 Abnormal skin pigmenta. 2.4 Hyperextensible skin

2.5 Ichthyosis

F. CARDIOVASCULAR1. Angioedema 2. Aortic dilatation3. Arrhythmia 4. Atrial septal defect 5. Coarctation of aorta6. Dilated cardiomyopathy7. Hypertension8. Hypertrophic cardiomyopathy9. Hypotension10. Lymphedema 11. Malf. of heart and great vessels12. Myocardial infarction13. Stroke14. Tetralogy of Fallot 15. Vasculitis 16. Ventricular septal defect

G. GASTROINTESTINAL,GENITOURINARY, ENDOCRINE

1. Gastrointestinal1.1 Aganglionic megacolon 1.2 Constipation 1.3 Diarrhea 1.4 Gastroschisis 1.5 Hepatic failure 1.6 Hepatomegaly 1.7 High hepatic transaminases 1.8 Obesity 1.9 Pyloric stenosis 1.10 Vomiting

2. Genitourinary 2.1 Abnormal renal

morphology 2.2 Abnormal urinary system 2.3 Hydronephrosis 2.4 Renal agenesis 2.5 Renal cyst 2.6 Renal tubular dysfunction

3. Endocrine3.1 Diabetes mellitus 3.2 Hyperparathyroidism 3.3 Hyperthyroidism 3.4 Hypoparathyroidism 3.5 Hypothyroidism

H. REPRODUCTION1. Abnormal external genitalia 2. Abnormal internal genitalia 3. Hypogonadism4. Hypospadias5. Infertility

I. ONCOLOGY 1. Adenomatous colonic polyposis2. Breast carcinoma

3. Colorectal carcinoma

4. Leukemia 5. Myelofibrosis6. Neoplasm of the lung 7. Neoplasm of the skin8. Paraganglioma 9. Pheochromocytoma

J. HEMATOLOGY ANDIMMUNOLOGY1. Abnormal hemoglobin

2. Abnormality of coagulation3. Anemia

4. Immunodeficiency5. Neutropenia6. Pancytopenia7. Splenomegaly8. Thrombocytopenia

K. PRENATAL AND DEVELOPMENT1. Abnormal facial shape 2. Failure to thrive3. Hemihypertrophy4. Hydrops fetalis 5. IUGR 6. Oligohydramnios7. Overgrowth8. Polyhydramnios 9. Premature birth10. Short stature11. Tall stature

Additional Clinical Information

**PHOTOCOPY REQUISITION AND INCLUDE 1 COPY WITH SAMPLES**


r')h

t > r- Ontario Ministry of Health and Long-Term Care Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health Services for Diagnostic

Laboratory Testing

An attending Ontario physician must complete the entire form. Print clearly to ensure form is legible.

Is the OOC testing required as a result of a work-related accident? 0Yes

For Ministry Use Only Reference Number

Date Received (yyyy/mm/dd)

If yes, do not complete this form, Please complete a Health Professional's Report (Form 8) and contact the Workplace Safety and Insurance Board (WSIB) at www.wsib.on.ca to discuss coverage. OHIP does not insure service(s) to which a person is entitled under the Worllease return to: Laboratories and Genetics Branch, Out of Country Program, 1075 Bay Street. 9th Floor, Toronto ON M7 A OAS.Applications may be faxed to 416-326-2211 or 1-844-642-0202. For fnformalion or clarification regarding this form, please call 1-844-648-7944.Part 1 - Patient

Last Name

Date of Birth (yyyy/mm/dd)

Current Malling Addreas Unit Number

I Street Number

City/Town

Telephone Number (Home)

··First Name Initials

Sex Health Number Version D Male O Female

I Street Name PO Box

Province Postal Code

Telephone Number (Business/Daytime) ext

Parent/Legal Guardian's Last Name (if applicable) Parent/Legal Guardian's First Name (if applicable)

Where this form is signed by a person who is not the applicant, indicate the relationship between the applicant and the person completing the form, D parent of child under 16 years of age O legal guardian O attorney under power of attorney 0 other (specify) ► If legal guardian, attorney or other, please provide copy of document which establishes that status or provide a consent signed by the patient permitting you to apply and communicate with the ministry on behalf of the patient if form is signed on behalf of person over the age of 16. Part 2 - Referring Ontario Physician Last Name

Office Address Unit Number

City/Town

Street Number

Telephone Number where we can reach you

I First Name

Street Name

Province

Fax Number ext.

Part 3 - Proposed OOC Health Facility / Diagnostic Laboratory / Hospital Facility CENTOGENE

Address Unit Number

City/Town ROSTOCK

4S21-B4E (2017/01)

Street Number Street Name SCHILLINGALLEE 68

State/Country GERMANY

Email Address (optional)

I Provider Billing No.

PO Box

Postal Code

PO Box

Postal Code 18057

Page 3 of 4

Name of: D 00C physician D Contact person Last Name First Name UEKERT ([email protected] CHRISTINE Telephone Number

ext. Fax Number Email Address

[email protected]

Part 4 - Testing Requested

Clinical Diagnosis (condition for which treatment is sought): Clinical Indication:

Reason service is required:

Please specify the laboratory test(s) required and attach a copy of the laboratory requlsltJon:

Have you previously requested and/or obtained this service in Ontario?

0 Yes (specify when and where)

[Z) No (specify reasons)

Have you previously requested and/or obtained this service out of the country?

0 Yes (specify when and where and provide reason for reapplication)

@No

Is this treatment generally accepted in Ontario as appropriate for a person in these medical circumstances? IZ)Yes QNo

Is this testing generally accepted as research or experimental In Ontario?□Yes @No

Is this testing performed in Ontario?□Yes [Z]No

Is this a genetic test? @Yes ONo

Part 5 - Signatures

Diagnostic Code

Note: Written approval must be received from the ministry before OOC health services are rendered. 0HIP does not pay for ambulance services, transportation costs, or out-of-hospital food, accommodation, drugs or prescriptions, including take-home prescriptions. All accompanylng documents will be considered as part of this application. I understand that the MOHL TC or its agents may collect, use or disclose personal health information and/or records relating to this application for the purposes of the administration of the Health Insurance Actincluding the administration of the 00C program. I understand that this may involve disclosure of personal health information and/or records related to any health care providers, institutions and agencies that require it as determined necessary by 0HIP. Collection of any of this infonnation is authorized by section 4.1 of the Health Insurance Act. For infonnation about MOHL TC collection practices, see our website at 111tp;/Jwww.heallh.gov,on.calenglishtp�...mgi�1io.nltJitU.:1��JH1f. It Is an offence to knowingly give false Information to the Ontario Health Insurance Plan In any application or statement made to the plan.

Comments

Name of Patient or Parent/Guardian Signature of Patient or Parent/Guardian Dale (yyyy/mm/dd)

Relationship to Patient (if not signed by patient) Please explain why form has not been signed by patient

I hereby declare the Information provided by me to be true. Signature of Referring Physician Date (yyyy/mm/dd)

4521-84E (2017/01) Page4 of4

Hereditary National Requisition 2019 - Dr. MunnUntitled

MOH-OOC-applic-Only-Centogene-info-fillable

ExPanel: OffSequencing + Deletion: OffProGx Panels: OffProg Panels Reference Number: WES: OffWES CNV: OffWES mtDNA: OffSamples: Solo: OffSamples: Trio: OffSamples: Trio Plus: OffGenome WGS: OffPatient Name: DOB: fastq 2: Offbam 2: Offvcf 2: OffData Selected Above: OffAdditonal Information or Instructions: Gene Name: Mutation: Full Analysis: OffSequencing: OffDeletion/Duplication: OffRepeat Expansion: OffFull Analysis (Fixed): OffSequencing (Fixed): OffData results consent: OffRelationship to person being tested: Signature Date: Consent Initials HCP: Consent Initials Patient: Consent Initials Patient 2: Check Box17: OffCheck Box16: OffCheck Box21: OffCheck Box20: OffCheck Box19: OffCheck Box22: OffCheck Box26: OffCheck Box25: OffCheck Box24: OffCheck Box23: OffCheck Box30: OffCheck Box29: OffCheck Box28: OffCheck Box27: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box37: OffCheck Box36: OffCheck Box35: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box144: OffCheck Box145: OffCheck Box151: OffCheck Box150: OffCheck Box149: OffCheck Box148: OffCheck Box147: OffCheck Box146: OffCheck Box154: OffCheck Box153: OffCheck Box152: OffCheck Box156: OffCheck Box155: OffAdditional Clinical Information: Valuable! Genetics staff will review phenotype information to improve diagnostic success rate. Optional: attach your clinical notes.Check Box10: OffCheck Box11: OffCheck Box12: OffCheck Box15: OffCheck Box14: OffCheck Box13: OffCheck Box18: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box73: OffCheck Box72: OffCheck Box71: OffCheck Box70: OffCheck Box69: OffCheck Box68: OffCheck Box79: OffCheck Box78: OffCheck Box77: OffCheck Box76: OffCheck Box75: OffCheck Box74: OffCheck Box82: OffCheck Box81: OffCheck Box80: OffCheck Box83: OffCheck Box84: OffCheck Box85: OffCheck Box86: OffCheck Box87: OffCheck Box88: OffCheck Box89: OffCheck Box90: OffCheck Box91: OffCheck Box92: OffCheck Box 10000: OffCheck Box93: OffCheck Box94: OffCheck Box95: OffCheck Box96: OffCheck Box97: OffCheck Box98: OffCheck Box99: OffCheck Box100: OffCheck Box101: OffCheck Box102: OffCheck Box103: OffCheck Box104: OffCheck Box105: OffCheck Box106: OffCheck Box107: OffCheck Box108: OffCheck Box109: OffCheck Box110: OffCheck Box111: OffCheck Box112: OffCheck Box113: OffCheck Box114: OffCheck Box115: OffCheck Box116: OffCheck Box117: OffCheck Box118: OffCheck Box122: OffCheck Box121: OffCheck Box120: OffCheck Box119: OffCheck Box123: OffCheck Box124: OffCheck Box125: OffCheck Box126: OffCheck Box127: OffCheck Box128: OffCheck Box131: OffCheck Box129: OffCheck Box130: OffCheck Box132: OffCheck Box133: OffCheck Box134: OffCheck Box135: OffCheck Box136: OffCheck Box137: OffCheck Box141: OffCheck Box139: OffCheck Box138: OffCheck Box140: OffCheck Box142: OffCheck Box143: OffButton11: YES: OffNO: YesPT I: PT HN v: PT TEL2: PT TEL2 EXT: PT LEGAL LAST: PT LEGAL FIRST: Check Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffSPECIFY: PH TEL2 EXT: FAXXX: 604-507-5214REASON FOR SERVE: Determine cause of clinical indications to support management of patient & inform relativesNO SPEC REASON: testing not performed in a designated ON labCOMMENTS: RELAT TO PAT: PLEASE EXPLAIN: CLIN IND: Diagnostic Code: CheckBox13: YesLast Name CONT: CarterFirst Name CONT: RonEMAILLL: [email protected]: Fax: e-mail: Copy to Name: Telephone 2: Fax 2: Copy to e-mail 1: Health Card #: Patient Tel: African: OffCaucasion: OffFrench Canadian: OffMiddle Eastern: OffNorth European: OffSouth Asian: OffEast Asian: OffAshkenazi Jewish: OffOther: OffNative: OffHispanic: OffSouth European: OffSoutheast Asian: OffPacific Islander: OffFamily Medical History: attach clinical notes to requisition (optional)No Additional: Offfamily ID: OffText1: Ministry of Health: OffInsitution: OffMin Of Health Approval: OffPrivate Pay: OffInstitution Name: Contact Name: Institution Billing Address: Contact Phone Prefix: Contact Phone Secondary Numbers: Contact Phone Last Numbers: Contact Fax Prefix: Contact Fax Secondary Numbers: Contact Fax Last Numbers: Contact email: Physiciant, Patient, Box: OffInformed Consent: OffInformed Consent 2: Offrandom1: OffClinical Features Checklist: OffClinical Features Checklist 2: OffInformed Consent 3: OffRandom 2: OffParental 1 & 2 requisitions: OffAddititional Family Member Req: OffBlood-Adult: OffBlood-Pediatric: OffPurified DNA: OffFilter Card: OffSample Type Other: OffSample Type Other Fill: Sample Collected M: MMSample Collected D: DDSample Collected Y: YYYYTime Collected: HH MMCollector Name: Clear Form: Ordering Physician Name - Last: Ordering Physician Name - First: LLG State/Country: British Columbia, CanadaLLG Postcode: V3H 1H8LLG Street Name: 130th StreetLLG StreetNumber: 7 455PT First: PT Unit Number: PT Street Number: PT Street Name: PT Postal Code: PT Province: PT City/Town: PT PO Box: Physician OHIP#: Physician MSC#: Unit Number: Street Number: Street Name: PO Box: City/Town: Province: Postal Code: Male Check: OffFemale Check: OffLL G City/Town: SurreyFacility: LifeLabs Genetics BCGene Test Code(s): Expanded Test Code(s): Gene Test Name(s): Expanded Test Name(s):

hereditary test requisition fast processing prenatal ... · blood-adult(2 x 4ml edta) 4005 acg ......

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