(Form to be used by General Practitioners to request cystic fibrosis carrier testing)
The Manchester Centre For Genomic Medicine is now able to offer cystic fibrosis carrier testing direct to
General Practitioners in either of the following two scenarios:
1.
For individuals at risk of cystic fibrosis carrier status by virtue of a family history of the disease
(either an affected family member or family member who is a confirmed cystic fibrosis carrier).
Or
2.
Individuals with a partner who is a confirmed cystic fibrosis carrier.
If your patient meets one of these criteria and would wish to undergo testing please complete this form
(page 2) fully for each patient referred for testing.
When complete please print out this form and send with a blood sample (3ml in EDTA) along with completed laboratory referral form (available at: http://www.mangen.co.uk/CubeCore/.uploads/Lab%20Documents/Useful%20documents/joint_referr al_form.pdf
). To:
Manchester Centre for Genomic Medicine
Genomic Diagnostics Laboratory
6 th Floor, St. Mary’s Hospital
Oxford Road
Manchester
M13 9WL
Please note that funding for this service is currently met by contracting arrangements established prior to the Health and Social Care Act 2012. Therefore until further notice the costs are covered by the former Greater Manchester, Cumbria and Lancashire commissioning arrangements. For referrals outside this geographical area please contact the laboratory for billing arrangements.
CF Carrier Testing FORM Page 1

Patient name:
Patient date of birth:
Click here to enter name.
Type in month and year then use “drop down box”.
Patient NHS number: Click here to enter NHS number.
Ethnicity: Click here to enter ethnicity.
Please complete either box 1 or 2 dependent upon the reason to request testing:
Box 1. If the individual is requesting carrier testing by virtue of a family history of the disease please describe the relevant family history including the names and dates of birth of individuals in the family who are known to have cystic fibrosis or are known to be a carrier of the disease. Please indicate family members who have had a diagnosis confirmed by genetic analysis in this laboratory
.
(if known)
Click here to describe family history.
Please draw pedigree by hand if known.
Box 2. If the individual is requesting carrier testing in order to inform pregnancy risk as they have a partner who is either affected by cystic fibrosis or is a carrier of the disease then it is essential that the partner has had a prior genetic confirmation of cystic fibrosis status in this laboratory. Please provide the name and date of birth of the partner.
Click here to enter name and date of birth of partner.
GP Name:
GP Address:
Click here to add GP name.
Click here to enter GP address.
GP Telephone number: Click here to enter GP phone number.
GP email: Click here to enter GP email.
Once completed please print this form to accompany the sample.
CF Carrier Testing FORM Page 2