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How to Order Caris Target Now
A formalin-fixed, paraffin-embed (FFPE) block or slides must be submitted in order for Caris Target Now molecular profiling
to be performed.
Requisition Form Instructions:
Medical Oncology
1) Complete the Treating Physician, Patient and Pathology information sections, as well as list any additional physicians that need to
be copied when the final report is released.
2) Select the appropriate Billing process. Patient is billed directly, a separate form is provided with payment information.
An agreed payment method is required prior to testing. The institution is billed, prior or after tumour profiling is performed,
based on agreement.
3) Document the Specimen Information, including Primary Tumour Site, Specimen Site, Specimen block ID#, Date of Collection and
Pathology Diagnosis.
4) Choose either the Caris Target Now Comprehensive Profile, one Caris Target Now Select profile or individual assay box.
A molecular profiling service must be selected in order for testing to be performed.
5) Collect the pathology report and if possible clinical history/most recent notes and fax to +41 21 533 53 01 / +800 12 12 32 32
or email to [email protected].
6) Contact your pathology department to request specimen be sent to Caris Life Sciences for molecular profiling.
Pathology Department
7) Place into the shipper kit: the specimen, pathology report, copy of the requisition form, and if possible clinical
history/most recent notes. If not done previously, fax the documents to +41 21 533 53 01 / +800 12 12 32 32 or email
to [email protected]
8) Call FedEx to arrange pick-up.
Formalin Fixed Paraffin Embedded (FFPE) Samples
Sufficient tumour must be present to complete all testing. If you have any questions, please contact Client Services.
SPECIMEN TY P E
S P E C I M E N R E Q U I R E M E NT S
Fixed Tissue
One (1) tumour-containing formalin fixed paraffin embedded block (FFPE) from most recent surgery
or biopsy. Tumour cells will be excised by microdissection from successive five micron sections of the
block until a total area of at least 15 mm2 is obtained for Caris Target Now Select profiles, and 30 mm2
for Caris Target Now Comprehensive.
Core Needle Biopsy
Four to six (4-6) biopsies formalin fixed paraffin embedded
t HBVHFOFFEMFQSFGFSSFE
t GPVSUPTJY
BTQJSBUFTBSFSFDPNNFOEFE
Fine Needle Aspirate (FNA)
One (1) formalin fixed paraffin embedded block from a cell block containing sufficient tumour
Unstained Slides
Unstained, positively charged, unbaked slides from one single, tumour-containing formalin fixed
paraffin embedded block; 5 micron sections
t$BSJT5BSHFU/PXSelect for Breast – 29 slides
t$BSJT5BSHFU/PXSelect for Colorectal – 15 slides
t$BSJT5BSHFU/PXSelect for Melanoma – 20 slides
t$BSJT5BSHFU/PXSelect for NSCLC – 26 slides
t$BSJT5BSHFU/PXSelect for Ovarian Surface Epithelial – 23 slides
t$BSJT5BSHFU/PXComprehensive for – 47 slides
Note: At least a 5mm x 5mm section of tissue per slide is
required. For small biopsies (tissue area < 5 mm x 5 mm)
please cut two sections per slide for at least one half of the
slides to ensure sufficient material for molecular assays.
Contact Caris Client Services with questions or to request a pick up at +41 21 533 53 00 / +800 12 12 30 30
or email to [email protected].
C A R I S TA R G E T N O W
Caris Target Now Tumour Profiling Requisition
A completed requisition and an agreed payment method are is required for Caris Target Now molecular profiling
to be performed, at a minimum please COMPLETE the highlighted areas. Client Services will contact you to
clarify any discrepancies and obtain the remaining information.
Caris Target Now™ Tumour Profiling Requisition
Complete and fax or e-mail requisition with copy of pathology report to +800 12 12 32 32 or +41 21 533 53 01 or [email protected].
The pathology report must bear the name of the originating institution and be stamped “controlled copy.”
Please send the original copy of the requisition with the specimen. All fields marked with an asterisk (*) are required.
Client Information
Enter the treating physician’s
contact information.
TREATING PHYSICIAN INFORMATION
PATIENT INFORMATION
* Office/Facility Name
* Last Name
Caris Account Number/Distributor
* First Name
Initial
* City
* Address
* City
* Country
* Phone Nr.
Fax Nr.
* Postal Code
* Country
* Postal Code
* Date of Birth (dd/mm/yyyy)
Age
Phone Number
* Sex
Email Address
PATHOLOGY INFORMATION
* Institution/Hospital Name
* Pathologist Name
* Institution/Hospital Address:
* City
* Phone Nr:
Billing Information
Billing information is required
to initiate testing.
Patient Information
Enter patient demographic
information here.
* Address
* Ordering Physician
* Country
* Fax Nr:
* Postal Code
Return Specimen Block To:
Pathology
Ordering Physician
Caris to Archive
Return addresses must be provided above in order to return block
Pathology Information
Enter the pathology information
in this section. Please include any
hospital/institution affiliation.
BILLING INFORMATION
Patients: An agreed payment method is required before testing starts. A separate form is provided to request payment information.
Hospitals/Clinics: Institutions will be billed after the tumour profiling is performed.
SPECIMEN INFORMATION Include a copy of the pathology report.
* Primary Tumour Type
Shipment Tracking #
* Specimen Site
* Specimen/Block ID#(s)
Date & Time of Collection
/
/
Duration of Fixation
Tissue Type(s):
FFPE Block
AM
PM
Unstained Slides
SERVICE REQUESTED (CHOICE REQUIRED) Choose one Caris Target Now Select profile, OR Caris Target Now Comprehensive, OR Individual Assay(s).
Indicate which profile is to be performed from the list below. The profiles will be performed as indicated. To order specific assays, choose from the individual assays. While every
attempt is made to keep this requisition current, the definitive list of assays included in each profile can be found online at www.CarisLifeSciences.eu/profilemenu.
Molecular Profiling Services
(CHOICE REQUIRED)
Clearly indicate which service
or individual assay is to be
performed..
A selection MUST be made.
Caris Target Now Select
Caris Target Now Comprehensive
Focused biomarker analysis for standard, tumour specific therapeutic associations
Breast
IHC:
ER
HER2
PR
PTEN
TLE3
FISH or
CISH:
HER2
TOP2A
RFLP:
ALK
Colorectal
RT-PCR:
BRCA1
ERBB3
ERCC1
RRM1
TOPO1
TS
Sequencing:
BRAF
KRAS
PIK3CA
IHC:
PTEN
RT-PCR:
AREG
EGFR
ERCC1
EREG
TOPO1
TS
Melanoma
IHC:
MGMT
PTEN
SPARCm
SPARCp
RT-PCR:
ERBB3
ERCC1
TUBB3
Sequencing:
BRAF
KRAS
NRAS
PIK3CA
RFLP:
ALK
Sequencing:
BRAF
cKIT
GNA11(uveal
melanoma only)
GNAQ (uveal
melanoma only)
NRAS
PIK3CA
Mutational
Analysis
by PCR:
BRAF
Broad biomarker analysis for therapeutic associations
across all tumour types
Ovarian Surface
Epithelial
NSCLC
IHC:
RT-PCR:
cMET
BRCA1
EGFR (H-score) EGFR
PTEN
ERCC1
TLE3
RRM1
TS
FISH or
CISH
Sequencing:
ALK
BRAF
cMET
EGFR
HER2
KRAS
PIK3CA
RFLP:
ALK
EGFR
IHC:
cMET
ER
HER2
PR
PTEN
TLE3
Comprehensive (AVAILABLE FOR ALL SOLID TUMOURS)
IHC:
AR
cMET
EGFR (H-score; NSCLC Only)
ER
HER2
MGMT
PR
PTEN
SPARCm
SPARCp
TLE3
RT-PCR:
BRCA1
ERBB3
ERCC1
RRM1
TOPO1
TOP2A
TS
Sequencing:
PIK3CA
FISH or CISH:
ALK (NSCLC only)
cMET
HER2
TOP2A (breast only)
Not all tests will result in a therapeutic association.
RT-PCR:
AREG
BRCA1
EGFR
ERBB3
ERCC1
EREG
Pgp
RRM1
TOPO1
TOP2A
TS
TUBB3
Sequencing:
BRAF
cKIT
EGFR (NSCLC only)
GNA11 (uveal melanoma only)
GNAQ (uveal melanoma only)
KRAS
NRAS
PIK3CA
Mutational Analysis
by PCR:
BRAF (melanoma only)
RFLP:
ALK
EGFR (NSCLC only)
Individual Assay (Due to the custom nature of individual test ordering, turn-around-time may differ from the above profiles)
IHC
FISH or CISH
AR
cMET
EGFR
(H-score;
NSCLC Only)
ER
HER2
MGMT
PR
PTEN
SPARCm
SPARCp
TLE3
RT-PCR
AREG
BRCA1
EGFR
ERBB3
ALK
cMET
HER2
TOP2A
This document constitutes an order by the treating
physician and an attestation of medical necessity.
Sequencing
ERCC1
EREG
Pgp
RRM1
TOPO1
TOP2A
TS
TUBB3
Physician or Practitioner Signature
BRAF
cKIT
EGFR
RFLP
GNA11
GNAQ
KRAS
NRAS
PIK3CA
Print Name
ALK
EGFR
Mutational Analysis by PCR
BRAF (melanoma only)
Date
CARIS TARGET NOW REPORT WILL BE DELIVERED IN ENGLISH. PLEASE SEE THE REVERSE FOR SPECIMEN REQUIREMENTS.
Specimen must be sent to Caris Life Sciences, Attn. Caris Target Now, 4610 South 44th Place, Phoenix AZ 85040, USA / CLIA 03D1019490
Caris Life Sciences Europe Customer Services Phone +800 12 12 30 30 or +41 21 533 53 00 / Fax +800 12 12 32 32 or +41 21 533 53 01 / E-mail [email protected].
Caris MPI, Inc. d/b/a Caris Life Sciences ©2012 Caris Life Sciences and affiliates. All rights reserved.
Physician or
Practitioner Signature
(SIGNATURE REQUIRED)
Signing the requisition authorises
Caris Target Now to perform
molecular profiling services.
EA61AE / Revision Date 6.19.2012
Fax completed requisition with copy of the pathology report,
clinical history and payment information to +41 21 533 53 01 / +800 12 12 32 32
or email to [email protected].
To order Caris Target Now™ services or
to speak with a Caris Life Sciences® representative, call
+ 41 21 533 5 3 0 0 / + 8 0 0 1 2 12 3 0 3 0
or email to [email protected],
or visit us online at www.carislifesciences.eu.
© 2012 Caris Life Sciences and affiliates. All rights reserved. EA50AE