Useful Forms

Clinical Referral Forms

• Urgent referrals to the genetics clinic
• Consent Form for Assessment by a Clinical Geneticist (patient deceased)
• Consent to access records and stored samples form
• Key Social Worker form
• Family history of cancer form
• NF1 clinical proforma
• NF2 clinical proforma

Laboratory Referral Forms:

• Genetic Testing Referral Form — for both cytogenetic (chromosomal) and molecular (DNA) testing.
• Specialist cell culture service referral form — for referral to the Specialist cell culture service
• The Willink Metabolic Unit referral form — for biochemical genetics testing
• The Willink Metabolic Unit Handbook

Specialist forms required for molecular pathology of solid tumours:

• Pharmacogenetics/Tumour referral form – To request testing for EGFR mutation testing (NSCLC); Colorectal NGS Panel (RAS/BRAF/PIK3CA); BRAF codon 600 mutations; KIT (melanoma); NRAS (melanoma); GIST screen (KIT/PDGFRA); FFPE BRCA1/2 for ovarian cancer; FFPE Somatic Colorectal Cancer NGS; NGS somatic cancer panel; MSI testing; MLH1 promoter hypermethylation; ALK and ROS re-arrangement by FISH
• Pharmacogenetics/Tumour referral form TARGET – To request NGS somatic cancer panel as part of the TARGET study
• Glioma referral form – To request all central nervous system tumour testing
• EGFR Plasma cfDNA referral form – To request EGFR plasma testing
• AstraZeneca EGFR Plasma cfDNA referral form – To request EGFR plasma testing for eligible samples
• Deceased Index referral form – To request testing of normal tissue for FFPE BRCA1/2; FFPE Colorectal Cancer NGS; Inherited cancer panel
• FFPE Colorectal Cancer Clinical pro-forma – to request FFPE Colorectal Cancer NGS panel (APC, BMPR1A, CDH1, CTNNB1, MSH6, SMAD4, MLH1, MSH2, MUTYH, POLD1, POLE, PTEN, STK11)

Additional forms:

• Request for genetic cystic fibrosis carrier testing — to be used by General Practitioners requesting cystic fibrosis carrier testing.
• Export Request Form (Molecular Genetics Testing) — required for all samples which need to be exported to other laboratories for molecular genetic testing.
• HD consent form — required for all samples referred for diagnostic testing of Huntington Disease. Presymptomatic tests should be referred through a Genetics Centre.
• NF1 clinical proforma — required for all samples received for mutation screening of the NF1 gene
• NF2 clinical proforma — required for all samples received for mutation screening of the NF2 gene
• Rare disease form — required for samples referred to the rare disease service