Test Request Form
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1GD Lab Case ID
Test Request Form
(Internal Use Only)
MD
_____________
Breast Cancer
Received:___________
To optimize the accuracy of the personalised Cancer Risk and Management Tool for the patient, please complete entire form to avoid delays.
1. REQUESTING PHYSICIAN INFORMATION
Full Name:
Address:
City:
Postcode:
Email
(<IMPORTANT> for report notification):
Phone:
Fax:
Signature of Requesting Physician:
Date:
or/and Genetic Counsellor Information
(recommended)
Full Name:
Address:
City:
Postcode:
:
Email
(<IMPORTANT> for report notification)
Phone:
Fax:
Yes
No
Send a copy of the report also to the Genetic Counsellor?
2. PATIENT INFORMATION
Male
Female
Last Name:
First Name:
Phone:
Reference/Medical Record Number:
Date of Birth:
DD / MM / YYYY
Ancestry
(check all that apply)
Ashkenazi Jewish
Asian
Aboriginal Australia
Near East/Middle East
European
African
Native New Zealand
Other:_____________
Patients Personal History of Cancer
(check all that apply)
No Personal History of Cancer
Bilateral
Premenopausal
Triple Negative
Breast Invasive
Age of
Diagnosis:________
Bilateral
Premenopausal
Triple Negative
Breast DCIS
Age of
Diagnosis:________
Ovarian Cancer
Age of
Diagnosis:________
Other Cancer(s)
Age of Diagnosis:
&
Tumour Pathology Report Attached
Family History of Cancer
No Family History
Family History
Maternal
Relationship
Paternal
Cancer
Age at Diagnosis
e.g. Aunt
Breast
45
3. TEST REQUESTED
Ashkenazi BRCA Founder Mutation Test
BRCA1/2 Comprehensive Test
BRCA1
BRCA2
Gene Panel
Predictive [Specify variant & attach proband
report:___________________________________
]
Express Service
(all except Gene Panel)
Sample Type
g/mL]
Blood
Buccal Swab
DNA [Concentration:
_________
4. PAYMENT
OPTION 1 Institutional
OPTION 2 Private
(Complete Private Payment Form)
Institution:
Contact Person:
Address:
Post Code:
Email:
Phone:
Purchase Order No:
Fax:
Contract No:
5.
Once Completed Fax to Genomic Diagnostics on +61 3 9918 2050 or Return With Kit
Genomic Diagnostics Website: Email: .au Address: 460 Lower Heidelberg Rd., Heidelberg
Vic 3084 Australia Postal Address: PO Box 250 Heidelberg West Vic 3081 Australia Phone: +61 3 9918 2020 Fax: +61 3 9918 2050 ABN 84 007190 043
MD-FORM-5-2015V4
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