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