Clinician Signature Date Ordered (YYYY-MM-DD)

Suite 204 - 2389 Health Sciences Mall,
tel: 778.379.2931
Vancouver, British Columbia, V6T 1Z3
fax: 778.379.3567
[email protected]
PAT I E N T I N F O R M AT I O N
Date of Birth
Patient Name (Last, First, Middle Initial)
Care Card Number
Gender
Issuing Province
Y Y Y Y- M M - D D
Male
Unit no.
Street Address
Postal Code
Province
City
R E F E R 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
Institution & Department
Institution & Department
Street Address
Street Address
City
Female
Province
Telephone
Postal Code
Fax
City
Province
Postal Code
Telephone
Fax
Email
Email
REASON FOR REFERR AL
TEST REQUESTED
Diagnostic Evaluation
CG001 Hotspot Mutation Cancer Panel (NGS)
Therapeutic target identification
ALK/RET/ROS1 Gene Fusion Assay (NGS)
Acquired resistance to drug, specify drug
KRAS Mutation Codons 12, 13 (Sanger Sequencing)
Other (please explain)
S P E C I M E N I N F O R M AT I O N
D I A G N O S I S & C L I N I C A L H I S T O RY
Organ Involved
Complete all applicable sections
Hospital
Block ID
Fixative: 10% Buffered Formalin
Diagnosis
FFPE Tissue (Block)
Additional Information (indicate all that apply)
Slides
No. sent
Other
specify
Primary tumor
Metastasis
Scrolls
No.
thickness
No. of tubes
Pre-treatment Sample
Post-treatment sample
Cores
No.
thickness
No. of tubes
Chemotherapy drug(s)
Previous Molecular Testing
PAT H O L O G Y I N F O R M AT I O N
Used for block returns
H&E slide included
Yes
No
5um unstained slide included
Yes
No
Pathology report included
Yes
No
Specimen Source:
Pathologist name
Institution name & address
Surgical resection specimen
Endoscopic biopsy
Fine needle aspiration biopsy
Core needle biopsy
Surgical biopsy
Other, specify:
Telephone
Email
All blocks will be returned to the Pathologist’s address
following reporting.
Tumor Information:
Tumor content (%)
L A B U S E O N LY
Cellularity (%)
Sample receipt date and time
Necrosis (%)
Initials
CG Laboratory number
Clinician Signature
Date Ordered (YYYY-MM-DD)
Ship to: Contextual Genomics, Inc. Suite 204 - 2389 Health Sciences
Mall, Vancouver, BC, V6T 1Z3
FFPE Block
Core
Other Information
Scrolls
H&E
Unstained Slide