DNA Diagnostics - Amsterdam UMC Genome Diagnostics

"*" indicates required fields

Note
Due to European legislation, all typed information of your patient will be erased when placing the order.
A secured email with the patients information will be sent to Amsterdam UMC Genome Diagnostics.

Patient information

Is this an application for a patient insured in the Netherlands?*

Yes

Are you going to use a patient sticker after printing the application form?*

Yes

Your reference

E.g. patient number own administration

Patient name*

Date of birth*

Gender*

Male

Female

Social Security Number*

Is the patient deceased?*

Yes

Concerns fetus*

Yes

Date of death*

Postpartum date*

Gestational age*

Declaration on another person*

Yes

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Street*

House number*

Postcode / ZIP*

Place*

Country*

Phone

Insurance*

Insurance number*

Family doctor

Address details family doctor

Declaration on another person

Name*

Date of birth*

Gender*

Male

Female

Social Security Number*

Insurance*

Insurance number*

Relation to patient*

Your reference

E.g. patient number own administration

Information Ordering Physician

AGB Code

AGB Code (for Dutch specialists only), see: AGB code register

Name*

First name Last name

Institution/Hospital*

Department

Medical specialty*

Street

House number

Postcode / ZIP

Place

Country*

Email address*

Phone*

Signal / Device

Additional reporting address

Yes

Email test results cc to

Name	Institution / Location	Medical specialty	E-mail address	Phone	Signal / Device	Actions

There are no Specialists.

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Test application

Test

Indication

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Test 1

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SKU 1

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Indicatie 1

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Code 1

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Addon 1

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Test 2

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SKU 2

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Indicatie 2

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Code 2

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Addon 2

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Test 3

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SKU 3

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Indicatie 3

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Code 3

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Addon 3

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Test 4

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SKU 4

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Indicatie 4

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Code 4

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Addon 4

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Test 5

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SKU 5

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Indicatie 5

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Code 5

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Addon 5

Sample material details

Nb. if CNV analysis in an NGS package is desired, only send freshly collected EDTA (anticoagulated) blood.

Sample type*

Blood

For adults 2x 6-7 ml, small children 5-10 ml / (never freeze, do not use 4 ml tubes).
Clearly indicate name, date of birth and gender on all blood tubes.

Date collected

Type

EDTA

PAX (RNA)

Umbilical cord blood

5-10 ml / (never freeze, do not use 4 ml tubes).
Clearly indicate name, date of birth and gender on the blood tubes. Also send mother’s blood.

Date collected

Type

EDTA

PAX (RNA)

Gestational age

Indicate gestational age

DNA

NGS panels 10μg, other tests 5μg.

DNA isolated from*

DNA isolated from

Date collected

Date collected*

Date collected

Gestational age

Indicate gestational age

DNA from tissue or other, namely

Description

Also send mother’s blood.

Saliva

Only when collected in Oragene OG-500 kits.

Date collected

Buccal swabs

Date collected

Biopt / Tissue

Volume 0.5 cm3. Note: muscle facie, NO muscle tissue

Date collected

Biopt / Tissue type

In paraffin

Yes

Cultured

Yes

Fibroblasts

Date collected

Chorion villi

Date collected

Gestational age

Indicate gestational age

Amnion

Date collected

Gestational age

Indicate gestational age

Cultured

Yes

Other sample material

Date collected

Mention sample

Indicate sample

Cultured

Yes

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Family

Has material from family member(s) been sent in previously to Amsterdam UMC?*

Yes, from the patient

Yes, from a family member

Not known

Samples relatives

Reference number	Name	Date of birth	Relation	Family number / FF(P) (if known)	Actions

There are no Family members.

Consanguinity in the family?*

Yes

Not known

Mention consanguinity

Indicate this in the pedigree on the printed order form.

Clinical information

Reason for testing*

Confirmation of clinical diagnosis

Confirmation of clinical suspicion

Carrier testing (recessive disease)

Pre symptomatic test

Prenatal testing

Genotyping for desired prenatal testing

Interpretation of previously found variant

Other

Confirmation of clinical diagnosis

Indicate clinical diagnosis*

Confirmation of clinical suspicion

Indicate clinical suspicion*

Carrier detection (recessive disease)

Indicate all relevant clinical data*

Pre symptomatic test

Indicate all relevant clinical data*

Prenatal testing

Indicate all relevant clinical data*

Genotyping for desired prenatal testing

Indicate all relevant clinical data*

Interpretation of previously found variant

Indication*

NB: Declaration on the index; Fill in data index at “Has material from family member(s) been sent previously to Amsterdam UMC?”

Other

Indicate the reason for this test application*

Clinical information additional to obesity

Length (cm)

Weight (kg)

Head circumference (cm)

Organ disorders (specify)

Dysmorphology (specify)

Autism*

Yes

Dominant inheritance*

Yes

Therapy resistance*

Yes

Mental disability*

Yes

Early onset (<5 year)*

Yes

Hyperphagy*

Yes

Developmental delay*

Yes

Clinical information additional to connective tissue disorders

Indication (for OI and EDS please state type)

Relevant family history

Relevant clinical information

Indicate aneurysms or dissections (type/situs)

Indicate other cardiovascular abnormalities

Indicate craniofacial dysmorphisms

Indicate eye abnormalities

Indicate hearing loss

Indicate skeletal abnormalities

Indicate skin abnormalities

Indicate joints

Indicate muscles

Indicate other

Clinical information additional to EpiSign tests

Age of patient at time of material collection*

Reason for EpiSign application

Clinical suspicion one of the EpiSign syndromes (see below)

Indicate variant with unknown clinical relevance (only genes mentioned in the list)

Syndrome (Imprinting disorders, Episignatures) – Gene/Region

Syndrome (Episignatures) – Gene/Region

Gene

Variant

Is the variant mosaic?

Yes

Estimated percentage

Is the clinical picture consistent with the associated syndrome?

Yes

Clinical information additional to neurogenetics

Conduction velocity Ulnaris m/s

Conduction velocity Medianis m/s

CMAP amplitude Ulnar mV

CMAP amplitude Medianis mV

Clinical information additional to preconception panel

Is there a medical indication for this application?

Yes

Indicate

Name partner

Partner's date of birth

Will partner's blood be submitted simultaneously?

Yes

Please submit a separate application form for the partner.

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Test analysis

Test analysis*

Complete analysis gen or panel

Specific analysis of a (familial) mutation

Gene and mutation

Please provide additional information about gene + variant and indication

Expedited testing required*

Yes

Only after consultation by telephone!
See: Contact with the laboratory for genome diagnostics (opens in new window ).

Result before

Note: Prenatal examination: 2 – 3 weeks / Familial mutation: 4 weeks

Contact with*

Executive lab

Which laboratory will the sample material be sent to?

Location AMC

Location VUmc

Notes

Indicate all other relevant information

Consent

Considering the use of material*

The patient or his legal representative DOES object to further use of the submitted bodily material.

The patient or his legal representative has NO objection to further use of the submitted bodily material.

Comments

This field is for validation purposes and should be left unchanged.