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CARIS MOLECULAR INTELLIGENCE™ TUMOURPROFILING
How to order Caris Molecular Intelligence™ Services
1. Patient Information
If you consider tumour profiling for one of your patients, the patient information leaflet supports you in
discussing this option with your patient. You can hand out a more detailed patient brochure if your patient
wants to read more about tumour profiling.
When you and your patient have decided to request profiling, you can use the patient consent
(if required in your country) to obtain formal patient consent for your own patient files.
Patient
information
! ?
2. Ordering
Please fill in the requisition form and fax or mail it to Caris Life Sciences (see contact details below).
Note: The MI profile service is updated frequently with published evidence, and printed requisition forms
may not include the latest service offerings.
Patient
consent
As tumour profiling is a new method which is not yet regularly covered by health insurances, the payment
information helps you to discuss payment options with your patient.
A pathology report is required to perform profiling. Please fax or mail the report to Caris, or ask your
pathology department to do so.
Additional information about the patient history is not a mandatory requirement but helpful for providing
the individual MI profile report.
Payment
Information
To obtain an electronic version of the current requisition form, please contact Caris Life Sciences or
download it from www.carislifesciences.eu/tumour-profiling-services.
3. Specimen Request
The pathology information form supports you in explaining the process and specimen requirements.
Please add a copy of the requisition form to enable your pathology department to identify the specimen.
Requisition
form
Contact your pathology department to request the specimen for tumour profiling.
4. Shipping the Sample
Pathology
information
For shipping of tissue samples Caris provides a shipper kit. Please inform Caris where you want the
shipper kit to be sent. Shipping is prepaid by Caris. The shipping process is described in the shipping
instructions.
If your pathology department sends out the the sample, provide Caris the contact details of
the recipient of the shipper kit, and fax the shipping instructions together with the pathology
information and requisition form to your pathology department.
5. Report
*The Caris team will contact you in case of additional requests (e.g. if quantity of tumour content requires prioritization of biomarker assessments).
6. Follow Up
If you have any further questions, additional needs and would like to speak to a member of Caris Life Sciences
stuff or Customer Services please contact Customer Services
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 – Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA152AE RO 04/28/14
Shipping
instructions
Caris will deliver the electronic MI Profile Report, usually within 14 days of receipt of the specimen
and required documentation in our laboratory.*
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Patient Information: Tumour Profiling
Patient
information
What is the best choice for your next cancer treatment?
Tumour profiling can help identify appropriate treatment options when:
• your cancer is no longer responding to standard treatment options
• your cancer is particularly aggressive or rare or has limited treatment options for other reasons
• The changes in your tumour are specific to your individual disease. This is the reason why patients respond
differently to cancer treatments.
• Tumour profiling thoroughly examines your cancer and matches treatments to the changes which are
particular to your tumour.
TUMOUR PROFILING
Patient
consent
Tumour profiling examines what is specific to your cancer
PERSONALISED MEDICINE
Payment
Information
Biomarker A
Biomarker B
Biomarker C
Biomarker D
Requisition
form
Biomarker E
Biomarker F
Caris Molecular Intelligence creates a fingerprint of your tumour
Caris Molecular Intelligence can help to
• Avoid treatments which are less likely to work for you
• Find clinical trials which you may be suitable for
Please note:
CMI has been introduced to you by your physician as this may be an option in your specific situation.
Please be aware that:
• CMI is a new method and may not be covered by health insurances in your country. This could mean that you have to
pay for the service yourself or negotiate with your health insurance provider.
• Not all drugs that may be reported as potentially effective may be available or reimbursed in your country.
• CMI may help your physician to identify treatment options which have a higher likelihood to work against your cancer,
but there is no guarantee that the chosen treatment will work.
See next page how it works
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA154AE RO 04/28/14
Shipping
instructions
Pathology
information
• Identify treatments which may work more effectively against your cancer
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Patient
information
What happens next?
1. Patient information, consent and payment
You will receive the patient information
You may be asked to sign a patient consent form
2. Collecting a tumour sample
NO
Is a tissue sample available
which is suitable
for tumour profiling?
YES
Patient
consent
You will be asked to agree to a method of payment for CMI
Payment
Information
Biopsy/Resection
3. Shipping your tumour sample to Caris
A local specialist doctor will arrange
shipment to the Caris laboratory.
Requisition
form
After this, for 8-10 days analysis of your
tumour will be performed in the Caris
laboratory.
4. Your physician receives the CMI report
Pathology
information
Your physician will discuss the result
and treatment options with you.
5. Treatment decision based on the CMI report
Shipping
instructions
Your physician will suggest your next treatments within the
context of local practice, guidelines, availability of drugs and
your physical condition and medical history.
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA154AE RO 04/28/14
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
As part of your continued care and as previously discussed with you, I, Dr___________________________________________
of _____________________________________________________________________ have recommended that your tissue
specimens in the form of one or more whole paraffin blocks, 55 unbaked slides or fresh tissue obtained from biopsies or other
procedures performed at your healthcare facility, be transferred to Caris Life Sciences (“Caris”) in the United States to perform the
Caris Life Sciences® Molecular Intelligence™ evidence guided tumour profiling service.
Caris Life Sciences® Molecular Intelligence™ examines the genetic and molecular changes unique to a patient‘s tumour, so that
treatment options may be matched to your tumour‘s unique biology. Caris Molecular Intelligence™ provides valuable information on those drugs which may be more likely to produce a positive response and those which may be less likely to.
Patient
consent
Dear Mr. / Mrs __________________________________ ,
Patient
information
Information for the Release of Biopsy/
Resection Tissue
Caris is based in the United States whose privacy laws may be different to those of your country of residence. Caris has implemented security measures, which aim to ensure that your personal data is protected from unauthorized or inadvertent disclosure and is only processed and stored for the purposes of conducting the Caris Molecular Intelligence™ analysis.
The transfer of your personal data to Caris is entirely voluntary. If you would prefer not to have Caris Molecular Intelligence™
Services performed, you do not have to give a reason. Your decision will not affect your regular treatment. If you choose not
to have Caris Molecular Intelligence™, we will not receive information about the genetic and molecular changes within your
tumour and we will not have the possibility to match treatment options to your tumour’s molecular profile. If you elect to have
Caris Molecular Intelligence™ Service performed, you will be asked to sign a consent form and will be given a copy of the signed
document to keep.
Requisition
form
As your designated healthcare provider, we will also transfer your personal data relating to the sample to Caris, and Caris will be
the only authorized recipient. The personal data transferred to Caris will include your name, patient number, and date of birth,
gender, address and pathology reports; as well as my name and the address of our healthcare facility. Caris will retain your personal data as required by all applicable regulations.
Payment
Information
The tissue specimens are being provided to Caris to enable them to perform the biomarker tests required to produce the Molecular Intelligence™ report (MI Profile™) only. As the profile of your tumour may change over time a recent sample is preferred,
you may be asked to submit to a procedure to collect this sample.
The specimen will be shipped overnight directly to Caris Life Sciences at the following address:
Caris Life Sciences
Attn: Molecular Intelligence™ Services
4610 South 44th Place
Phoenix, AZ 85040
Thank you for your attention reading this document. If you have any further questions please do not hesitate to ask.
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA153AE RO 04/28/14
Shipping
instructions
Once the analysis has been performed on the sample, any slides made from the sample and any remaining tissue will be returned to the hospital for storage or disposal, based on their local protocol.
Pathology
information
You have the right to obtain certain information about how your personal data is being processed and to receive a copy of the
personal data held about you. You also have the right to ask to correct any inaccurate personal data held about you. You may
object to the processing of your personal data on legitimate grounds and to request the anonymisation, removal and/or blockage of your personal data. Such a request should be addressed in writing to me at the address set out above.
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Please ask your patient
to sign this document.
Based on the information received by Dr.___________________________________ I, ______________________________ ,
accept and request the release of my tissue specimens in the form of one or more whole paraffin blocks, 55 unbaked slides or
fresh tissue, obtained from biopsies or procedures performed at my healthcare facility, to Caris Life Sciences.
Patient
information
Consent for the Release of Biopsy/
Resection Tissue
I further understand that once the analysis has been performed on the sample, any slides made from the sample and any remaining tissue will be returned to the treating hospital or on request, may be stored at or disposed of by Caris Life Sciences based
on our local protocols.
Patient
consent
I understand that this request is being made for the purposes of analysis that will provide information that may aid in treatment
decisions for my continued care. I also authorize the provision to Caris Life Sciences of all corresponding final pathology reports
and the transfer to and processing of my personal data by Caris Life Sciences for the purposes of conducting the Caris Molecular
Intelligence™ analysis. I also understand that I may decline or withdraw my authorization at any time.
I acknowledge that this specimen will be shipped overnight directly to Caris Life Sciences at the following address:
Payment
Information
Caris Life Sciences
Attn: Molecular Intelligence™ Services
4610 South 44th Place
Phoenix, AZ 85040
Requisition
form
I understand that I can ask Dr.__________________________________ if I have any questions.
INSTITUTION / HOSPITAL NAME
………………………………………………………
REQUESTING PHYSICIANPATIENT NAME
DATE, SIGNATUREDATE, SIGNATURE
Shipping
instructions
………………………………………………………………………………………………………………………..
Pathology
information
………………………………………………………………………………………………………………………..
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA153AE RO 04/28/14
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Dear Patient,
The cost of tumour profiling is not yet routinely covered by health insurances in all countries. Caris is in discussion with private
and public health insurances to obtain full coverage. Until then, it is necessary that an alternative mechanism of payment is
agreed with Caris before testing can commence.
Patient
information
Payment Information
The following payment options are available:
You, or a friend or relative, can pay Caris directly for the tumour profiling service. Caris will contact you and provide you with an
invoice as soon as we receive a completed Tumour Profiling Requisition Form from your physician. It is therefore necessary that
your doctor provides Caris with your contact details when filling in the requisition form.
Patient
consent
Self-pay
If you have supplementary or private health insurance, or if you have your healthcare costs covered by another institution such
as an embassy or employer, your doctor will need to provide this information on the requisition form, together with the respective contact details. Caris need to have a payment authorisation from the institution before testing can commence. This is usually
obtained by your physician.
Health Insurances without Pre-Profiling Payment-Authorisation
Caris currently has a special program for patients with health insurance companies who have not yet agreed to pay for our tumour profiling service regularly and thus may not yet provide payment authorsation prior to profiling. If your doctor agrees to
make a special request for coverage to your health insurance, both prior to and after tumour profiling, Caris will process the case
after a modest up front payment has been received.
• If the insurance company pays Caris directly, the initial up front payment will be refunded to you.
• If the insurance company pays you for the full costs of profiling directly, Caris will invoice you for the balance.
Requisition
form
Third Party Funding (Pre-Authorised Payment by Health Insurances, Embassies, Employers)
Pathology
information
Even if you have already paid for Caris Molecular Intelligence in full, it may be worth applying for coverage from your local health
insurance, especially if your doctor selects your next treatment from those indicated on the MI Profile report.
Payment
Information
All payment options will be communicated to you once Caris has received the completed Tumour Profiling Requisition Form
from your doctor.
Shipping
instructions
For this purpose, Caris needs your consent that your doctor can share your clinical history, your insurance details and the results
of the health insurance application with Caris, in addition to your contact information.
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA156AE RO 04/28/14
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Billing Information
Billing information is
required
to initiate testing.
Tumour Profiling
Services
(CHOICE REQUIRED)
Clearly indicate which
service
or individual assay
is to be
performed.
A selection MUST be
made.
Next-Generation
Sequencing
Expand the
Comprehensive report
with additional
sequencing markers
for a more in-depth
tumour profile.
Physician or
Practitioner Signature
(SIGNATURE REQUIRED)
Signing the requisition
authorises Caris to perform
tumour profiling
services.
Fax completed requisition with copy of the pathology report
and clinical history to +41 21 533 53 01 / +800 12 12 32 32
or email to [email protected].
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
Patient
consent
Payment
Information
Pathology Information
Enter the pathology
information
in this section. Please
include any
hospital/institution
affiliation.
Requisition
form
Patient Information
Enter patient
information here.
Pathology
information
Customer
Information
Enter the treating
physician’s
contact information.
Shipping
instructions
A completed requisition form is required for tumour profiling to be performed, at a minimum please
COMPLETE the highlighted areas. Customer Services will contact you to clarify any discrepancies and obtain
the remaining information.
Patient
information
Tumour Profiling Requisition Instructions
International 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.
TREATING PHYSICIAN INFORMATION
PATIENT INFORMATION
* Office/Facility Name
Caris Account Number/Distributor
* Last Name
* Ordering Physician
Physician Email Address
* Address
* First Name
* City
* Address
* City
* Country
* Phone Nr.
Fax Nr.
* Country
* Date of Birth (dd/mm/yyyy)
* Postal Code
Initial
* Postal Code
* Gender
q Male q Female
Phone Number
Email Address
PATHOLOGY INFORMATION (Include a copy of the pathology report)
* Institution/Hospital Name
* Pathologist Name
* Institution/Hospital Address: * City * Country * Phone Nr: * Fax Nr: * Postal Code
Return Specimen Block To: q Pathology q Ordering Physician q Caris to Archive
Return addresses must be provided above in order to return block
BILLING INFORMATION
q Self-pay: Payment is required before testing starts. Caris Customer Services will contact the patient directly to agree payment terms.
q Health Insurance: A reimbursement request has been sent to patient’s health insurance.
Insurance Company: _________________________________ Policy # ______________________ Pre-Authorisation / Authorisation #: _____________________ (if available)
q Hospitals/Clinics: Institution will be billed after testing has been performed.
q Other, please specify: _________________________________________________________________________________________________________________________
SPECIMEN INFORMATION Include a copy of the pathology report.
* Primary Tumour Type
Shipment Tracking #
* Specimen Site
* Specimen/Block ID#(s)
Tissue Type(s):
q FFPE Block
q Unstained Slides
Date & Time of Collection
/
/
Duration of Fixation
AM
PM
TUMOUR PROFILING SERVICES (Choice Required)
Select a panel or individual assay(s) to be performed from the list below. See reverse side for profile details. The MI Profile panel is updated frequently with the published
evidence. While every attempt is made to keep this printed requisition current, the definitive list of biomarkers should be verified on-line before ordering at
www.CarisLifeSciences.eu/profilemenu.
PANELS
INDIVIDUAL ASSAY(S)
q MI Profile™
IHC
Multi-platform, solid tumour biomarker analysis for therapeutic decision support and clinical trials matching (see reverse for profile
details), includes next generation sequencing (NGS)
m AR
m cMET
m EGFR
m EGFR (H-score;
Helpful when:
• treating aggressive, rare or refractory cancers
• looking for clinical trial opportunities
NSCLC Only)
m ER
m ERCC1
m HER2
m MGMT
m MLH1*
m MSH2*
m MSH6*
m PD-1
m PD-L1
m Pgp
m PMS2*
m PR
m PTEN
m RRM1
m SPARCm
m SPARCp
m TLE3
m TOPO1
m TOP2A
m TS
m TUBB3
FISH or CISH
m ALK
m cMET
m HER2
m ROS1
m TOP2A
Mutational Analysis
m Solid Tumour Cancer Panel (47 genes, NGS) m BRAF (cobas® PCR)
m EGFRvIII (Fragment Analysis) m IDH2 (SangerSeq)
m MGMT-Me (PyroSeq)
m MSI* (Fragment Analysis)
m Individual Next-Generation
Sequencing Genes (List the genes to be reported. See reverse for panel):
*performed for CRC cases only
Please share a copy of the final report with:
q Pathology
q Other (please specify) __________________________________________________
NOTICE: This requisition constitutes an order for services. I certify
that the services are medically indicated and necessary, and that
they will assist me in treating my patient.
Physician or Practitioner Signature
Email: ___________________________________________________
Print Name
Date
FINAL REPORT WILL BE DELIVERED IN ENGLISH. PLEASE SEE THE REVERSE FOR SPECIMEN REQUIREMENTS.
Terms and conditions apply. Visit www.CarisLifeSciences.eu/tumour-profiling-services to view the terms and conditions in full.
Specimen must be sent to Caris Life Sciences, 4610 South 44th Place, Phoenix AZ 85040, USA / CLIA 03D1019490 / ISO 15189:2012 – 3531.01
International 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 ©2014 Caris Life Sciences and affiliates. All rights reserved.
EA61FE / Revision Date March 25, 2014
By submitting this requisition, you, as the patient’s physician, represent and verify that the patient has provided clear, unambiguous and explicit consent to send the
patient’s specimen and sensitive medical and other personal information to Caris Life Sciences, and to transfer that information to the United States for processing.
Additionally, you represent that you and your office have abided by all EU, national and local privacy requirements and regulations related to this service.
Profile Menu
Select a panel or individual assay(s) to be performed from the list below. See reverse side for profile details. The MI Profile panel is updated frequently with the published
evidence. While every attempt is made to keep this printed requisition current, the definitive list of biomarkers should be verified on-line before ordering at
www.CarisLifeSciences.eu/profilemenu.
Tests may vary if insufficient tumour samples are submitted. Please refer to the specimen requirements below for more information.
MI Profile™
IHC
FISH / CISH
AR, cMET, EGFR (H-score; NSCLC only), ER, ERCC1
(ovarian only), HER2, MGMT (excluding glioma),
MLH1 (CRC only), MSH2 (CRC only), MSH6 (CRC only),
PD-1, PD-L1, Pgp, PMS2 (CRC only), PR, PTEN, RRM1,
SPARCm, SPARCp, TLE3, TOP2A, TOPO1, TS, TUBB3
cMET*, HER2*,
TOP2A* (breast only),
ALK* (NSCLC only),
ROS1* (NSCLC only)
Mutational Analysis
Next-Generation Sequencing
Other
See MI Profile Next-Generation
Sequencing Genes below.
BRAF (PCR, melanoma only),
EGFRvIII (Frag. Analysis; glioma only),
IDH2 (SangerSeq; glioma only),
MGMT-Me (PyroSeq; glioma only)
MSI (Frag. Analysis; CRC only)
Next-Generation Sequencing Cancer Panel
ABL1
BRCA2
CTNNB1
FGFR2
HRAS
MLH1
PIK3CA
AKT1
BRAF
EGFR
FLT3
IDH1
MPL
PTEN
SMO
ALK
CDH1
ERBB2 (HER2)
GNA11
JAK2
NOTCH1
PTPN11
STK11
SMARCB1
APC
cKIT
ERBB4
GNAQ
JAK3
NPM1
RB1
TP53
ATM
cMET
FBXW7
GNAS
KDR (VEGFR2)
NRAS
RET
VHL
BRCA1
CSF1R
FGFR1
HNF1A
KRAS
PDGFRA
SMAD4
MI Profile includes biomarkers associated with commercially available cancer therapies or clinical trials for the same or different tumor type. Other biomarkers outside MI Profile are also available; and, are
known to be associated with cancer, but may have other clinical utilities including: predictive, prognostic or diagnostic associations.
* Assay may be performed by an external reference laboratory.
Formalin Fixed Paraffin Embedded (FFPE) Samples
Sufficient tumour must be present to complete all analysis. If you have any questions, please contact Customer Services at +800 12 12 30 30.
SPECIMEN TYPE
S PE C IM E N R E Q U IR E M E N T S
Fixed Tissue
One (1) tumour-containing formalin fixed paraffin embedded block (FFPE) from most recent surgery or biopsy. Successive four (4) micron sections will be created from the block until sufficient material for the testing orders is obtained. For the molecular analysis, tumor cells will be excised by microdissection until a total area of at least 50mm2 is obtained. Tumour cells will be excised by microdissection from successive five (5) micron sections of the block until a total area of at least 15 mm2 is obtained for both the MI Profile panel.
Core Needle Biopsy
Four to six (4-6) biopsies formalin fixed paraffin embedded
• 18 gauge needle preferred
Fine Needle Aspirate (FNA)
One (1) formalin fixed paraffin embedded block containing sufficient tumour
Unstained Slides
Unstained, positively charged, unbaked slides from one single, tumour-containing formalin fixed paraffin embedded block; 5 micron sections
• MI Profile - 55 slides
• Next-Generation Sequencing only - 15 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.
Malignant Fluid
One (1) formalin fixed paraffin embedded cell block containing sufficient tumour.
Formalin Samples
Sufficient tumour must be present to complete all analysis. If you have any questions, please contact Customer Services at +800 12 12 30 30.
SPECIMEN TYPE
SPECIMEN REQUIREMENTS
Fresh Tissue
Two (2) or more samples with a minimum thickness of ~3mm (height, width, length) and submit in 10% neutral buffered formalin.
Core Needle Biopsy
Four to six (4-6) biopsies
• 18 gauge needle preferred
Bone/Bone Metastasis
Two (2) or more samples with minimum thickness of 3mm (height, width, length) and submit in 10% neutral buffered formalin (DO NOT DECALCIFY)
Insufficient Specimen Quantity – Prioritisation of Tests
In the event that a specimen is received with an insufficient quantity of tissue or insufficient percent tumour required to perform the entire profile or
individual tests indicated on the requisition, Caris Life Sciences will email the ordering physician the proposed list of tests. The physician may amend this
list to include any tests that are offered within the test menu. The ordering physician should review the proposed list of tests within 72 hours in order to
provide timely results. Please note: turnaround time may be longer for specimens with limited tissue.
Specimen must be sent to Caris Life Sciences, 4610 South 44th Place, Phoenix AZ 85040, USA / CLIA 03D1019490 / ISO 15189:2012 – 3531.01
International 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 ©2014 Caris Life Sciences and affiliates. All rights reserved.
EA61FE / Revision Date March 25, 2014
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Please send this specimen
request together with the filled
in tumour profiling requsition
form to your patholgoy.
Patient
information
Specimen Request for Tumour Profiling
at Caris Life Sciences
To :
Pathology Department ………………………………………………………………..
Pathologist Name
………………………………………………………………..
Patient Name
Patient
consent
With the following patient I have agreed that a tumour profile will be performed at Caris Life Sciences
(see carismolecularintelligence.eu/en for details).
………………………………………………………………..
Date of birth
Payment
Information
Specimen/Block ID#
(if available)
Please prepare the specimen for tumour profiling as specified in the attached requisition form.
Specimen requirements are listed on page 2 of the form.
Please deliver the specimen to my department so that I can send it out.
Please send the Specimen to Caris Life Sciences. The shipping instructions are attached.
Please include in the shipper kit:
• the specimen
• a copy of the requisition form
• a copy of the pathology report
• a frozen cool block (part of the Caris Shipper Kit)
Requisition
form
In cases of questions related to sample preparation or shipping, please contact Caris Life Sciences:
Pathology
information
International Customer Services
Phone +41 21 533 53 00 / +800 12 12 30 30
Email: [email protected]
Department
………………………………………………………………..
Date ………………………………
Signature ……………………………………………………………
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA155AE RO 04/28/14
Shipping
instructions
Physician name ………………………………………………………………..
CARIS MOLECULAR INTELLIGENCE™ TUMOUR PROFILING
Please ensure a representative sample(s) of malignant tissue is sent for tumour profiling. A final pathology report is required
before the Caris Molecular Intelligence™ service can begin. Please see specimen requirements, on reverse side of Tumour
Profiling Requisition form, for more information.
Specimen Preparation and Packing Instructions
Insert collected specimen into shipper.
• Place blocks in provided clear plastic bags and insert into foam holders.
• Insert slides into provided plastic cassettes (slide container).
Patient
information
Paraffin Block/Slide Shipper Kit Instructions
Patient
consent
15 mm2 area of tumour cells required
Payment
Information
Place FROZEN cold pack in shipper.
Requisition
form
Place cooler lid on top to ensure specimen integrity during transport.
Insert shipper kit into clear laboratory shipping pack and seal.
1. Insert the completed Fedex airway bill and customs invoice into the Fedex shipping
documentation envelope and attach on the outside of the clear laboratory shipping pack
and seal
2. Contact your local FedEx Client aServices to schedule pickup. Please tell Fedex the Caris
Fedex account number (see section 7 of the fedex airway bill) guaranteeing you a free
delivery of the specimen.
We advise you to contact Caris Customer Service at +800 1212 3030 or +41 21 533 53 01 or email
to [email protected] with the package tracking number (a 12 digit number on the
bottom right hand side of the fedex airway bill), to allow us to monitor the delivery.
Caris Life Sciences Europe, 199, St. Jakobsstrasse – Basel 4052 – Switzerland
Tel +800 12 12 30 30 / +41 21 533 53 00 - Fax +800 12 12 32 32 / +41 21 533 53 01
www.carislifesciences.eu
EA155AE RO 04/28/14
Shipping
instructions
Pathology
information
Fax (+800 12 12 32 32) or email ([email protected])
the completed requisition form and pathology report to Caris
Customer Service. Then, place the completed requisition form and
pathology report on top of the cooler and close shipper.