Cardiomyopathy Familial Mutation Pre-referral form

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Cardiomyopathy Familial Mutation Pre-referral form
Please send 10mls of EDTA blood or DNA to: Molecular Genetics Laboratory, The Churchill Hospital, Headington, OXFORD, OX3 7LJ.
Contact: Clinical:
Dr Ed Blair
[email protected]
01865 226008
Laboratory: Kate Thomson [email protected] 01865 225586
Referrals will only be accepted from the following:
Referrer
Please select
Consultant Clinical Geneticist
Minimum criteria required for testing:
Criteria
Please select
Unaffected relative of proband with known pathogenic mutation (Predictive test)
Affected relative of proband with known pathogenic mutation (Diagnostic test)
Referrer Details:
REFERRER DETAILS
Name:
Address for report: -
Specialty: - (please circle)
Genetics
Cardiology
Post code: Address for Invoice:
Post code: Telephone: -
Fax No: -
E-mail: -
Patient Details:
PATIENT DETAILS
Forename:
D.O.B: Address: -
Surname: NHS No.:
Your Ref. No.: Post Code: -
Additional Information: -
Details of familial mutation:
Family member in whom mutation was identified:Relationship to this patient:Gene:Mutation nomenclature:Additional info.:-
In submitting this sample the clinician confirms that genetic counseling has been undertaken and
consent for testing has been obtained.
P:\Specialist Services\UKGTN\Gene Dossiers\GDs 2007-2008 comm cycle\testing criteria for 0708 comm cycle\Testing criteria - Oxford
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