Cardiovascular Disorders

1-844-363-4357· [email protected]
Schillingallee 68 · 18057 Rostock Germany
British Columbia Laboratory Requisition
This requisition form, when completed, constitutes a referral to LifeLabs/BC Biomedical Laboratories physicians.
Please ship NON-PRENATAL SAMPLES to:
LIFELABS • Attn: CDS Department 100 International Boulevard• Toronto ON• M9W6J6
Attention Patient: Please visit your nearest LifeLabs or BCBiomedical Patient Service Centre for sample collection
TO BE COMPLETED BY ORDERING DOCTOR AND PATIENT
Gender
Patient Name (from CareCard or other ID)
Male
Patient Address
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Female
Patient Email
YEAR
MONTH
DAY
Bill to Patient:
(no charge at PSC)
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Copy to
Genetic Test - mnemonic ACG (Blood sample 2 x 4mL EDTA)
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Genetic Test (Other Sample Type) - mnemonic OCG (other sample type)
PRENATAL SAMPLES: Please ship directly to CENTOGENE.
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relationship to person being tested:
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**Laboratory Staff: Photocopy Requisition and include one copy with samples in box**
LL-GCG-001 - Ver 1 - JULY 2014
Page 1/5
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V2 October 2014
GENETIC TESTING REQUISITION
CARDIOVASCULAR DISORDERS
1-844-363-4357· [email protected]
Patient Name:
` Sample Type:
Schillingallee 68 · 18057 Rostock Germany
Patient DOB (YYYY/MM/DD):
□ *Blood (EDTA: 5mL for single gene, 10mL for panel)
□ DNA (single gene:1-10ug, panel 10-100ug)
□ *Filter card (1 card/30 exons: Available by request)
□ Saliva (Oragene OG-510: Available by request)
□ Fibroblast/Skin Biopsy (0.5cm )
□ Cultured cells (1 flask, min 25cm , 80-90% confluent)
□ **Amniotic fluid (10mL)
□ **Chorionic Villus (10 villi, cleaned)
□ Other: _________________________________________________________
2
2
* Exact amount depends on size of panel, see www.centogene.com
** Please contact us prior to sending cells
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provincial health plan
Cardholder Signature: _______________________________________ Date (DD/MM/YYYY)________________
Patient Information:
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Additional patient medical information:
Relevant Family history:
Have other family members submitted samples to Centogene for analysis?
If yes, Name:_______________________
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Familial Mutation Testing
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** PLEASE INCLUDE A COPY OF REQUISITION WITH SAMPLES **
Page 2/5
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V2 October 2014
GENETIC TESTING REQUISITION
CARDIOVASCULAR DISORDERS
1-844-363-4357· [email protected]
Patient Name:
Schillingallee 68 · 18057 Rostock Germany
Patient DOB (YYYY/MM/DD):
` Please indicate requests for Hot Spot (H), Exon (E), Sequencing (S), Repeat Expansion (R) and/or Deletion/Duplication (D) analysis
Arrhythmias
NGS Panels:
D
S
D
S
D
S
D
S
Arrhythmia, hereditary panel
Brugada syndrome panel
Catecholaminergic polymorphic
ventricular tachycardia panel
Long QT syndrome panel
(AKAP9,ANK2,CACNA1C,CACNB2,CASQ2,CAV3,DSC2,DSG2,DSP,GPD1L,JUP,KCNA5,KCNE1,KCNE2,KCNE3,KCNH2,KCNJ2,KCNQ1,
NPPA,PKP2,PLN,RYR2,SCN1B,SCN3B,SCN4B,SCN5A,SNTA1,TGFB3,TMEM43)
(CACNA1C, CACNB2, GPD1L, HCN4, KCNE3, SCN1B,SCN3B, SCN5A, SLMAP)
(RYR2, CASQ2, KCNJ2)
(AKAP9, ANK2, CACNA1C, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNJ5, KCNQ1, SCN4B, SCN5A, SNTA1)
Single genes:
D
S
Long QT syndrome type 1 (KCNQ1)
D
S
Long QT syndrome type 2 (KCNH2)
D
S
Long QT syndrome type 3 (SCN5A)
D
S
Long QT syndrome type 4 (ANK2)
D
S
Long QT syndrome type 5 (KCNE1)
Atrial fibrillation type 11 (GJA5)
D
S
Long QT syndrome type 6 (KCNE2)
S
Brugada syndrome type 1 (SCN5A)
D
S
Long QT syndrome type 8 (CACNA1C)
D
S
Brugada syndrome type 2 (GPD1L)
D
S
Long QT syndrome type 9 (CAV3)
D
S
Brugada syndrome type 3 (CACNA1C)
D
S
Long QT syndrome type 10 (SCN4B)
D
S
Brugada syndrome type 4 (CACNB2)
D
S
Long QT syndrome type 11 (AKAP9)
D
S
Brugada syndrome type 5 (SCN1B)
D
S
Long QT syndrome type 12 (SNTA1)
D
S
Brugada syndrome type 6 (KCNE3)
D
S
Long QT syndrome type 13 (KCNJ5)
D
S
Brugada syndrome type 7 (SCN3B)
D
S
Progressive familial heart block (TRPM4)
D
S
Brugada syndrome type 8 (HCN4)
D
S
Short QT syndrome type 1 (KCNH2)
H
D
S
Brugada syndrome type 9 (SLMAP)
D
S
Short QT syndrome type 2 (KCNQ1)
H
D
S
Catecholaminergic polymorphic Ventricular tachycardia type 1 (RYR2)
D
S
Short QT syndrome type 3 (KCNJ2)
H
D
S
Catecholaminergic polymorphic Ventricular tachycardia type 2 (CASQ2)
H
D
S
Sick sinus syndrome type 1 (SCN5A)
D
S
Catecholaminergic polymorphic Ventricular tachycardia type 3 (CALM2)
H
D
S
Sick sinus syndrome type 3 (MYH6)
D
S
Catecholaminergic polymorphic Ventricular tachycardia type 4 (CALM1)
H
D
S
Sudden infant death syndrome (SCN5A)
H
D
S
Heart block type 1 (SCN5A)
H
D
S
Ventricular fibrillation, paroxysmal familial type 1 (SCN5A)
H
D
S
Jervell and Lange-Nielsen syndrome type 1 (KCNQ1)
D
S
Ventricular tachycardia, familial (GNAI2)
E
D
S
Jervell and Lange-Nielsen syndrome type 2 (KCNE1)
D
S
Wolff -Parkinson-White syndrome (PRKAG2)
H
H
H
D
S
Atrial fibrillation type 3 (KCNQ1)
D
S
Atrial fibrillation type 4 (KCNE2)
D
S
Atrial fibrillation type 6 (NPPA)
D
S
Atrial fibrillation type 7 (KCNA5)
D
S
Atrial fibrillation type 10 (SCN5A)
D
S
D
H
H
E
H
H
Cardiomyopathies
NGS Panels:
D
S
D
S
D
S
Arrhythmogenic right ventricular
cardiomyopathy panel
Cardiomyopathy dilated panel
Cardiomyopathy hypertrophic panel
(DSP, DSG2, DSC2, JUP, PKP2, RYR2, TMEM43)
(ABCC9, ACTC1, ACTN2, BAG3, CSRP3, DES, DMD, DSG2, EYA4, FKTN, GATAD1, LAMP2, LDB3, LMNA, MYBPC3, MYH6, MYH7, MTND1, MT-ND5, MT-ND6, MT-TD, MT-TH, MT-TI, MT-TK, MT-TL1, MT-TL2, MT-TM, MT-TQ, MT-TS1, MT-TS2, NEXN, PLN, PSEN1, PSEN2,
RBM20, SCN5A, SDHA, SGCD, TAZ, TCAP, TMPO, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL)
(ACTC1, CALR3, CAV3, CSRP3, GLA, JPH2, LAMP2, MYBPC3, MYH6, MYH7, MYL2, MYL3, MYLK2, MYOZ2, NEXN, PLN, PRKAG2,
SLC25A4, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL)
Single genes:
D
S
Arrhythmogenic right ventricular cardiomyopathy type 1 (TGFB3)
D
S
Arrhythmogenic right ventricular cardiomyopathy type 5 (TMEM43)
D
S
Cardiomyopathy, dilated type 1CC (NEXN)
D
S
D
S
Arrhythmogenic right ventricular cardiomyopathy type 8 (DSP)
Cardiomyopathy, dilated type 1D (TNNT2)
D
S
D
S
Arrhythmogenic right ventricular cardiomyopathy type 9 (PKP2)
Cardiomyopathy, dilated type 1DD (RBM20)
H
D
S
D
S
Cardiomyopathy, dilated type 1E (SCN5A)
Arrhythmogenic right ventricular cardiomyopathy type 10 (DSG2)
H
D
S
D
Cardiomyopathy, dilated type 1EE (MYH6)
S
Arrhythmogenic right ventricular cardiomyopathy type 11 (DSC2)
E
D
D
S
Arrhythmogenic right ventricular cardiomyopathy type 12 (JUP)
D
S
Barth syndrome (TAZ)
H
D
S
H
D
H
Cardiomyopathy, dilated type 1G (TTN)
D
S
Cardiomyopathy, dilated type 1HH (BAG3)
D
S
Cardiomyopathy, dilated type 1I (DES)
Cardiomyopathy, dilated (MYBPC3)
D
S
Cardiomyopathy, dilated type 1L (SGCD)
S
Cardiomyopathy, dilated type 1A (LMNA)
D
S
Cardiomyopathy, dilated type 1M (CSRP3)
D
S
Cardiomyopathy, dilated type 1AA (ACTN2)
D
S
Cardiomyopathy, dilated type 1N (TCAP)
D
S
Cardiomyopathy, dilated type 1C (LDB3)
D
S
Cardiomyopathy, dilated type 1O (ABCC9)
H
Page 3/5
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V2 October 2014
1-844-363-4357· [email protected]
GENETIC TESTING REQUISITION
CARDIOVASCULAR DISORDERS
Patient Name:
`
Schillingallee 68 · 18057 Rostock Germany
Patient DOB (YYYY/MM/DD):
Cardiomyopathies (continued)
D
S
Cardiomyopathy, dilated type 1P (PLN)
H
D
S
Cardiomyopathy, familial hypertrophic type 10 (MYL2)
H
D
S
Cardiomyopathy, dilated type 1R (ACTC1)
H
D
S
Cardiomyopathy, familial hypertrophic type 11 (ACTC1)
H
D
S
Cardiomyopathy, dilated type 1S (MYH7)
D
S
Cardiomyopathy, familial hypertrophic type 12 (CSRP3)
D
S
Cardiomyopathy, dilated type 1T (TMPO)
D
S
Cardiomyopathy, familial hypertrophic type 16 (MYOZ2)
D
S
Cardiomyopathy, dilated type 1U (PSEN1)
D
S
Cardiomyopathy, familial hypertrophic type 17 (JPH2)
D
S
Cardiomyopathy, dilated type 1V (PSEN2)
D
S
Cardiomyopathy, familial hypertrophic type 19 (CALR3)
D
S
Cardiomyopathy, dilated type 1W (VCL)
H
D
S
Cardiomyopathy, familial restrictive type 1 (TNNI3)
D
S
Cardiomyopathy, dilated type 1X (FKTN)
E
D
S
Cardiomyopathy, fatal (MT-TI)
H
D
S
Cardiomyopathy, dilated type 1Y (TPM1)
D
S
Cardiomyopathy, hypertrophic, midventricular, digenic (MYLK2)
H
D
S
Cardiomyopathy, dilated type 1Z (TNNC1)
E
D
S
Cardiomyopathy, idiopathic dilated, mitochondrial (MT-TH)
H
D
S
Cardiomyopathy, dilated type 2A (TNNI3)
H
D
S
Fabry disease (GLA)
D
S
Cardiomyopathy, dilated type 2B (GATAD1)
D
S
Danon disease (LAMP2)
D
S
Cardiomyopathy, dilated type 3B (DMD)
H
D
S
McKusick-Kaufman-Syndrome (MKK)
D
S
Cardiomyopathy, dilated type J (EYA4)
E
D
S
MELAS syndrome (MT-TF)
D
S
Cardiomyopathy, dilated with woolly hair and keratoderma (DSP)
E
D
S
MELAS syndrome (MT-TL1)
H
D
S
Cardiomyopathy, familial hypertrophic (CAV3)
E
D
S
MERRF syndrome (MT-TK)
H
D
S
Cardiomyopathy, familial hypertrophic type 1 (MYH7)
E
D
S
MERRF/MELAS overlap syndrome (MT-TS1)
H
D
S
Cardiomyopathy, familial hypertrophic type 2 (TNNT2)
E
D
S
MERRF/MELAS overlap syndrome (MT-TS2)
H
D
S
Cardiomyopathy, familial hypertrophic type 3 (TPM1)
D
S
Mitochondrial myopathy and sideroblastic anemia type 1 (PUS1)
H
D
S
Cardiomyopathy, familial hypertrophic type 4 (MYBPC3)
E
D
S
Mitochondrial myopathy, isolated (MT-TD)
D
S
Cardiomyopathy, familial hypertrophic type 6 (PRKAG2)
E
D
S
Myopathy (MT-TQ)
D
S
Cardiomyopathy, familial hypertrophic type 7 (TNNI3)
D
S
Myopathy, lactic acidosis, and sideroblastic anemia type 2 (YARS2)
D
S
Cardiomyopathy, familial hypertrophic type 8 (MYL3)
D
S
Myopathy, mitochondrial (MT-TM)
Cardiomyopathy, familial hypertrophic type 9 (TTN)
D
S
Sengers syndrome (AGK)
H
H
E
D
Vascular
NGS Panels:
D
S
Aortic aneurysm, hereditary thoracic panel
(MYH11, ACTA2, TGFBR1, TGFBR2, FBN1, COL3A1, SMAD3, CBS, FBN2, SLC2A10, MYLK, TGFB2)
D
S
Ehlers-Danlos syndrome panel
(COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, FKBP14, PLOD1, TNXB)
D
S
Marfan syndrome and related disorders panel
(ACTA2,COL3A1,COL5A1,COL5A2,FBN1,FBN2,MYH11,SLC2A10,SMAD3,TGFBR1, TGFBR2)
Single genes:
H
H
D
S
Angioedema, hereditary (SERPING1)
H
D
S
Ehlers-Danlos syndrome type 3 (COL3A1)
D
S
Antithrombin III deficiency (SERPINC1)
H
D
S
Ehlers-Danlos syndrome type 4 (COL3A1)
D
S
Aortic Aneurysm, familial thoracic type 1 (MYH11)
D
S
Ehlers-Danlos syndrome type 4 (COL5A1)
D
S
Aortic Aneurysm, familial thoracic type 1 (TGFBR1)
D
S
Fabry disease (GLA)
D
S
Aortic Aneurysm, familial thoracic type 1 (TGFBR2)
D
S
Glycoprotein Ia C807T polymorphism (ITGA2)
D
S
Aortic Aneurysm, familial thoracic type 1 (FBN1)
D
S
Homocystinuria (CBS)
D
S
Aortic aneurysm, familial thoracic type 6 (ACTA2)
D
S
Homocystinuria (MTHFR)
D
S
Aortic Aneurysm, familial thoracic type 7 (MYLK)
D
S
Homocystinuria, B12-responsive (MTR)
D
S
Aortic valve disease type 1 (NOTCH1)
D
S
Homocystinuria-megaloblastic anemia, cbl E type (MTRR)
D
S
Aortic valve disease type 2 (SMAD6)
D
S
Hypertension, ADD2-related(ADD2)
D
S
Arterial Hypertension, idiopathic pulmonary (BMPR1B)
D
S
Hypertension early onset (NR3C2)
D
S
Arterial Tortuosity Syndrome (SLC2A10)
D
S
Loeys-Dietz syndrome type 1C (SMAD3)
D
S
Bernard Soulier syndrome type A1 (GP1BA)
D
S
Loeys-Dietz syndrome type 2A (TGFBR1)
D
S
Bernard Soulier syndrome type A2 (GP1BA)
D
S
Loeys-Dietz syndrome type 2B (TGFBR2)
D
S
Bernard Soulier syndrome type B (GP1BB)
D
S
Loeys-Dietz syndrome type 4 (TGFB2)
D
S
Bernard Soulier syndrome type C (GP9)
D
S
Hypertension early onset (NR3C2)
D
S
CADASIL (NOTCH3)
D
S
Loeys-Dietz syndrome type 1C (SMAD3)
D
S
Capillary malformations, congenital (GNAQ)
D
S
Loeys-Dietz syndrome type 2A (TGFBR1)
D
S
CARASIL (HTRA1)
D
S
Loeys-Dietz syndrome type 2B (TGFBR2)
D
S
Cerebral cavernous malformations type 1 (KRIT1)
D
S
Loeys-Dietz syndrome type 4 (TGFB2)
D
S
Cerebral cavernous malformations type 2 ((CCM2)
D
S
Marfan syndrome (FBN1)
D
S
Cerebral cavernous malformations type 3 (PDCD10)
D
S
Mitochondrial myopathy and sideroblastic anemia 1 (PUS1)
D
S
Coronary artery disease in familial hypercholesterolemia, protection against
(ABCA1)
D
S
D
S
Ehlers-Danlos syndrome type 1/2 (COL5A1)
D
S
Myoglobinuria acute recurrent (LPIN1)
D
S
Ehlers-Danlos syndrome type 1/2 (COL5A2)
D
S
Myopathy with lactic acidosis hereditary (ISCU)
H
H
H
H
Page 4/5
Moyamoya disease type 2 (RNF213)
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V2 October 2014
1-844-363-4357· [email protected]
GENETIC TESTING REQUISITION
CARDIOVASCULAR DISORDERS
Patient Name:
`
Schillingallee 68 · 18057 Rostock Germany
Patient DOB (YYYY/MM/DD):
Vascular (continued)
D
S
Orthostatic intolerance (SLC6A2)
D
S
Pseudohypoaldosteronism type 2D (KLHL3)
D
S
Plasminogen activator inhibitor type 1 (SERPINE1)
D
S
Pseudohypoaldosteronism type 2E (CUL3)
D
S
Protein C Deficiency, AD (PROC)
D
S
Sturge-Weber syndrome (GNAQ)
D
S
Protein S Deficiency, AD (PROS1)
Other
NGS Panels:
D
S
D
S
D
S
Central hypoventilation syndrome panel
(RET, GDNF, EDN3, BDNF, ASCL1, PHOX2A, PHOX2B, ZEB2, GFRA1, ECE1, MECP2)
Heterotaxy panel
( ACVR2B, CFC1, CRELD1, GJA1, GDF1, FOXH1, LEFTY2, NKX2-5, NODAL, ZIC3)
Noonan – Cardiofaciocutaneous syndrome panel (BRAF, CBL, HRAS, MAP2K1, KRAS, MAP2K2, NF1, NRAS, RAF1, PTPN11, SHOC2, SOS1, SPRED1)
Single genes:
H
H
H
H
D
S
Alveolar capillary dysplasia with misalignment of pulmonary veins (FOXF1)
R
S
Central hypoventilation syndrome with or without Hirschsprung disease (PHOX2B)
D
S
Atrial septal defect type 2 (GATA4)
D
S
CHARGE syndrome (CHD7)
D
S
Atrial septal defect type 3 (MYH6)
D
S
Costello syndrome (HRAS)
D
S
Atrial septal defect type 9 (GATA6)
D
S
DiGeorge (22q11.2 deletion) syndrome (TBX1)
D
S
Atrial septal defect with atrioventricular conduction defects (NKX2-5)
D
S
Dopamine beta-hydroxylase (DBH) deficiency (DBH)
D
S
Atrioventricular septal defect, partial with heterotaxy syndrome (CRELD1)
D
S
Heterotaxy, visceral type 1 (ZIC3)
D
S
Atrioventricular septal defect type 5 (GATA6)
D
S
Heterotaxy, visceral type 2 (CFC1)
D
S
Cardiac valvular dysplasia, X-linked (FLNA)
D
S
Heterotaxy, visceral type 4 (ACVR2B)
D
S
Cardioencephalomyopathy, fatal infantile: cytochrome c oxidase def'cy (SCO2)
D
S
Heterotaxy, visceral type 5 (NODAL)
D
S
Cardiofaciocutaneous syndrome (KRAS)
D
S
LEOPARD syndrome 3 (BRAF)
D
S
Cardiofaciocutaneous syndrome (BRAF)
D
S
Noonan syndrome like (SHOC2)
D
S
Cardiofaciocutaneous syndrome (MAP2K1)
D
S
Noonan syndrome type 1 (PTPN11)
D
S
Cardiofaciocutaneous syndrome (MAP2K2)
D
S
Noonan syndrome type 3 (KRAS)
D
S
Congenital heart disease and transposition of the great arteries (FOXH1)
D
S
Noonan syndrome type 4 (SOS1)
D
S
Central hypoventilation syndrome, congenital (RET)
D
S
Noonan syndrome type 5 (RAF1)
D
S
Central hypoventilation syndrome, congenital (GDNF)
H
D
S
Noonan syndrome type 6 (NRAS)
D
S
Central hypoventilation syndrome, congenital (EDN3)
H
D
S
Noonan syndrome type 7 (BRAF)
D
S
Central hypoventilation syndrome, congenital (BDNF)
D
S
Noonan syndrome-like disorder with or without juvenile meylomonocytic
leukemia (CBL)
D
S
Central hypoventilation syndrome, congenital (ASCL1)
D
S
Pancreatic agenesis and congenital heart defects (GATA6)
D
S
Central hypoventilation syndrome, congenital (PHOX2A)
D
S
Pulmonary fibrosis, idiopathic (SFTPA1)
D
S
Central hypoventilation syndrome, congenital (ZEB2)
D
S
Pulmonary newborn hypertension (CRHR1)
D
S
Central hypoventilation syndrome, congenital (GFRA1)
D
S
Tetralogy of Fallot (ALDH1A2)
D
S
Central hypoventilation syndrome, congenital (ECE1)
D
S
Tetralogy of Fallot (GATA6)
D
S
Central hypoventilation syndrome, congenital (MECP2)
D
S
Transposition of great arteries, dextro-looped 3 (GDF1)
H
Page 5/5
The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited.
Requisition V2 October 2014

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