MOLECULAR DIAGNOSTICS FACILITY – ONCOLOGY SERVICE
Leeds Genetics Laboratory (Cytogenetics) ISO 15189 Accredited Laboratory (UKAS 8105)
St. James’s University Hospital, Beckett Street, Leeds LS9 7TF
http://www.leedsth.nhs.uk/genetics
Head of laboratory: Paul Roberts BSc, FRCPath.
Tel: 0113 2065419
PATIENT DETAILS/patient ID label
Fax: 0113 2066201
mod.lth@nhs.net
Email:
Referrer details
Surname:
Consultant:
Forename(s):
Hospital:
D.O.B.:
Phone:
NHS No:
Sex:
CDF No:
Fax:
nhs.net email:
Patient’s Address:
Copies of results to:
Postcode:
Clinical details
Sample type
Pathology /Specimen number:
Block number(s):
 Paraffin embedded
 Fresh
 Biopsy
 Cytology
 Resection
Tumour type:
 Blood
 CSF
 Other
% tumour nuclei within circled area(s):
Non tumour sample 
Date sample was taken:
Genetic Testing required: Please tick or specify other:
Mutation
 EGFR
 KRAS
 NRAS
 BRAF
 IDH1/IDH2
 KIT/PDGFRA
 Other
FISH
 ALK
 Chr 1p/19q
 N-MYC
 WT1
 DDIT3
 MDM2
 FOXO1
 FUS
 SS18
 EWSR1
 P53/MPO
 RB1
 HER2
 COL1A1/PDGFB
 SMARCB1
 JAZF1
 USP6
 Other FISH
RNA Studies
 RT-PCR for BRAF Fusion
Others
 MGMT methylation
 Whipples
 Karyotype
 Other (Please specify)
Requested by:
Laboratory Use Only
 Microsatellites (specimen mix up)
Date of request:
Lab No.
Date of receipt:
CDLG002 v1.3 Jan 2016