TGLclinical Brookes-Lawley Building Institute of Cancer Research 15 Cotswold Road Sutton, Surrey, SM2 5NG Email: [email protected] Phone: 020 8722 4122 Molecular Genetic Test REQUEST FORM PATIENT DETAILS FIRST NAME(S): Website: www.tglclinical.com CLINICAL DETAILS: Ethnic Origin / Nationality (helpful for result interpretation): ..………………………………………. Unaffected SURNAME: Affected Cancer 1: …............................................................ Age of diagnosis: ....................... Cancer 2: …............................................................ Age of diagnosis: ....................... Cancer 3: …............................................................ Age of diagnosis: ....................... HOSPITAL NUMBER: Other clinical features/suspected syndrome: DATE OF BIRTH: Family history/test eligibility criteria: GENDER: NHS: SELF-PAY: NHS NUMBER: PRIVATE: POSTCODE: REQUESTING CLINICIAN: MOLECULAR GENETIC TEST(S) REQUESTED: Gene(s): ........................................................................................................................................ Name: ...................................................................... Signature: ................................................................ Date required: ............................................................................................................................. (If result is required by specific date.) Date: ......................................................................... Full gene(s) Email: …………………………………………………. Specific mutation(s) Mutation(s):............................................................................................. Tel: ……………………………………………………… (Contact details above required in case of sample query. Results will be returned to Requesting Consultant) REQUESTING CONSULTANT: Lab/Hospital where mutation detected: …............................................................................. Proband Details: Name: ………………………………….………………..……………………………….…..…... D.O.B.: …………………………………………………………………………………..…….…. Name: ....................................................................... Hospital / Unit: .......................................................... SPECIMEN DETAILS PLEASE ENSURE NAME AND AT LEAST ONE OTHER IDENTIFIER IS ON TUBE Blood : EDTA tubes ONLY (Adults: 2x 9ml, Children 1-5ml): Hosp number:…………………………………….................................................................. Other details (if applicable): .................................................................................................... DNA storage only PLEASE NOTE: On receipt of this sample, the laboratory staff assume the appropriate consent(s) have been obtained. FOR LABORATORY USE ONLY LOGGED IN BY: TGL FAMILY NUMBER: Other (specify): ….............................................. TGL LAB BARCODE: Sample Collection: DATE RECEIVED: Date: ……………………………………………………. TIME RECEIVED: Time: …………………………………………………… Sample taken by: ..................................................... TGL_F_22 | Form | Molecular Genetic Test REQUEST FORM| v4 – 20141017