Find-It™
(CG001) Hotspot Cancer Panel (NGS)
REQUISITION FORM
PAT I E N T I N F O R M AT I O N
Date of Birth
Patient Name (Last, First, Middle Initial)
Issuing Province
Care Card Number
Sex
Hospital No.
Male
O R D E R I N G P H Y S I C I A N I N F O R M AT I O N
ADDITIONAL PHYSICIAN (S) TO BE COPIED
Name
Name
Practitioner #
Institution
Institution
Department
Department
Address
Address
City
Province
Country
Email
Telephone
Postal Code
City
Province
Country
Email
Postal Code
Fax
S P E C I M E N I N F O R M AT I O N
REASON FOR REFERR AL
Female
Practitioner #
Telephone
Fax
Y Y Y Y- M M - D D
Complete all applicable sections
Hospital
Therapeutic target identification
Sample ID
Acquired resistance to drug
(specify drug)
Other
(please explain)
Date of Procedure
Fixative: 10% Buffered Formalin
Other
Y Y Y Y- M M - D D
(specify)
FFPE Tissue (Block) - PREFERRED
D I A G N O S I S & C L I N I C A L H I S T O RY
Slides
No.
/thickness
Diagnosis
Scrolls
No.
/thickness
No. of tubes
Cores
No.
/thickness
No. of tubes
Stage
Additional Information (indicate all that apply)
Primary tumour
Metastasis
Pre-treatment Sample
Post-treatment sample
DNA
(ng/ul)
Include one of:
Undergoing Treatment
H&E slide
Yes
No
5µm unstained slide
Yes
No
Digital H&E image
Yes
No
Specimen Source:
Chemotherapy drug(s)
Previous Molecular Testing
PAT H O L O G Y I N F O R M AT I O N
Name
Used for block returns
Practitioner #
Surgical resection
Endoscopic biopsy
Fine needle aspirate
Core needle biopsy
Surgical biopsy
Other
Tumour Information:
Institution
Cellularity (%)
Department
Pathology report included
Address
C G L A B U S E O N LY
City
Country
Postal Code
Province
Email
Telephone
Sample Receipt Date
Necrosis (%)
Yes
Y Y Y Y- M M - D D
CG Laboratory number
Fax
Accessioned by
No
Time
0 0:0 0
Initials
Checked by
Comments
C L I N I C I A N S I G N AT U R E A N D C O N S E N T
My signature constitutes a certificate of medical necessity and informed consent. As the ordering physician, I certify that the patient
has been informed of the benefits, risks and limitations of the test being performed and that consent has been obtained from him/her
to perform this testing. In addition, I have discussed with my patient that her/his test results and DNA will be kept indefinitely by CG
to be used for internal quality control and/or for anonymized research.
Ordering Clinician Signature
Date Ordered (YYYY-MM-DD)
Ship To:
Contact Information:
Vancouver, British Columbia, V6T 1Z3
fax: 778.379.3567
Suite 204 - 2389 Health Sciences Mall,
tel: 778.379.2931
test@contextualgenomics.com
Instructions for Completing the Requisition Form
Section 1. Patient Information
Please complete all the requested patient information in this section.
Section 2. Ordering Physician/Laboratory Information
All ordering physicians and laboratories must provide complete contact information, including practitioner number. A secure Fax
number (including area code) must be provided in order for Contextual Genomics to send reports. If you require the report to be
provided to any additional physicians or laboratories please complete the Additional Physicians to be Copied section.
Section 3. Reason for Referral
Indicate reason for referral and provide any relevant additional information.
Section 4. Diagnosis and Clinical History
Please provide comprehensive information regarding clinical history and diagnosis as this information will be important in the
interpretation of genomic findings and drug therapy recommendations. Include any previous molecular test results including gene fusion
FISH results.
Section 5. Pathology Information
The contact information provided will be used for block returns. Complete all fields and ensure providing a secure Fax number
(including area code) for receiving results. Tumour information must include cellularity and necrosis. Please enclose a copy of the
pathology report with the sample.
Section 6. Specimen Information
•
Indicate the hospital where the
•
If you are not sending a block, specify what type of sections
specimen was processed
are being sent (scroll, core or unstained slides).
•
Provide sample ID
•
Indicate number of sections or slides and thickness and
number of tubes (scrolls and cores only)
•
Indicate date of procedure
•
Select whether you are sending an H&E slide, 5 um
(YYYY/MM/DD)
unstained slide or a digital image
•
Provide sample fixation method
Ensure the ordering clinician has signed and dated the requisition form.
National Access Program for Cancer Testing Sample Requirements
Please ensure all samples are accompanied by a pathology report.
General Guidelines
•
Tumour samples should be fixed in 10% buffered formalin optimally for no longer than 48 hours. If fixation was longer than 48
hours, please notify us as this can lead to sub-optimal assay performance due to degradation of DNA templates.
•
Decalcified FFPE samples cannot be accepted.
•
Blocks from resection specimens should have a minimum of 1cm x 1cm tissue content (for small biopsies the nearest amount
to this specification is acceptable).
•
Samples sent for testing should optimally consist of at least 50% nuclear tumour content for optimal assay performance;
however, the assay is valid to 10% tumour nuclear content.
Any of the following options will be accepted as sample submissions for CG001 testing
Specimen
Description
Additional Requirements
FFPE
Blocks are requested. All blocks will be returned once the case has been
Pathology lab address for block return
Block
reported. If blocks are not available, specimen types listed below will be
accepted.
Scrolls
2 x 1.5 ml centrifuge tubes containing 4 scrolls each of 5 m sections OR
H&E or digital image from the same
2 x 1.5 ml centrifuge tubes containing 2 scrolls each of 10 m sections
FFPE block OR
5 m slide for staining
Cores
1 x 1.5 ml centrifuge tube containing 2 cores of 0.6mm diameter or
H&E slide or digital image from pregreater
cored section with site of coring marked
Unstained 5 slides of 10 m sections OR 10 slides of 5 m sections
H&E or digital image from the same
Slides
FFPE block OR
additional unstained 5 m slide
DNA*
150ng at 25-100ng/ul concentration
H&E or digital image from the same
FFPE block
* We prefer to do the DNA extraction in-house
Please Note: For small tissue samples, such as fine needle aspirates (FNA), for which blocks are not submitted, please include H&E
slides or images pre- and post-sectioning. We will only accept FNA if no other specimen is available. Please be aware that FNA
specimens may not yield sufficient material for analysis, particularly if material is nearly exhausted from other analyses.
Contextual Genomics Inc.
Suite 204 – 2389 Health Sciences Mall,
Vancouver, British Columbia, V6T 1Z3
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