TGLclinical
Brookes-Lawley Building
Institute of Cancer Research
15 Cotswold Road
Sutton, Surrey, SM2 5NG
Email: tgl@icr.ac.uk
Phone: 020 8722 4122
Molecular Genetic Test
REQUEST FORM
PATIENT DETAILS
FIRST NAME(S):
Website: www.tglclinical.com
CLINICAL DETAILS:
Ethnic Origin / Nationality (helpful for result interpretation): ..……………………………………….
Unaffected
SURNAME:
HOSPITAL NUMBER:
Affected
Cancer 1: …............................................................
Age of diagnosis: .......................
Cancer 2: …............................................................
Age of diagnosis: .......................
Cancer 3: …............................................................
Age of diagnosis: .......................
Other clinical features / suspected syndrome / family history / eligibility criteria:
DATE OF BIRTH:
GENDER:
NHS:
SELF-PAY:
NHS NUMBER:
PRIVATE:
POSTCODE:
For BRCA please include protocol code(s), e.g. A1 : ……………………………………………
REQUESTING CLINICIAN:
MOLECULAR GENETIC TEST(S) REQUESTED:
Gene(s): ........................................................................................................................................
Name: ......................................................................
Signature: ................................................................
Date required: .............................................................................................................................
(If result is required by specific date.)
Date: .........................................................................
Full gene(s)
Email: ………………………………………………….
Specific mutation(s) Mutation(s):.............................................................................................
Tel: ………………………………………………………
(Contact details above required in case of sample query.
Results will be returned to Requesting Consultant)
REQUESTING CONSULTANT:
Lab/Hospital where mutation detected: ….............................................................................
Proband Details:
Name: ………………………………….………………..……………………………….…..…...
D.O.B.: …………………………………………………………………………………..…….….
Name: .......................................................................
Hospital / Unit: ..........................................................
SPECIMEN DETAILS
PLEASE ENSURE NAME AND AT LEAST ONE
OTHER IDENTIFIER IS ON TUBE
Blood : EDTA tubes ONLY
(Adults: 2x 9ml, Children 1-5ml):
Hosp number:……………………………………..................................................................
Other details (if applicable): ....................................................................................................
DNA storage only
PLEASE NOTE:
On receipt of this sample, the laboratory staff assume the appropriate consent(s) have
been obtained.
FOR LABORATORY USE ONLY
LOGGED IN BY:
TGL FAMILY NUMBER:
Other (specify): …..............................................
TGL LAB BARCODE:
Sample Collection:
DATE RECEIVED:
Date: …………………………………………………….
TIME RECEIVED:
Time: ……………………………………………………
Sample taken by: .....................................................
TGL_F_22 | Form | Molecular Genetic Test REQUEST FORM| v5 – 20150211