©2019 Mayo Foundation for Medical Education and Research
T519
MC1235-98rev0619
Instructions: The accurate interpretation and reporting of genetic results is contingent upon the reason for referral, clinical information, ethnic
background, and family history. To help provide the best possible service, supply the information requested below and send this paperwork
with the specimen or return by fax to Mayo Clinic Laboratories, Attn: Molecular Genetics Lab Genetic Counselors at 507-284-1759.
Patient Information
Patient Name (Last, First, Middle) Birth Date (mm-dd-yyyy) Gender
Male Female
Provider Name (Last, First) Phone Fax*
Genetic Counselor Name (Last, First) Phone Fax*
*Fax number provided must be from a fax machine that complies with applicable HIPAA regulations.
Reason for Testing
Study Purpose Diagnostic Presymptomatic
If more than one test is ordered, should all tests be performed at the same time? Yes No
If no, indicate preferred order of testing: ________________________________________________________________________
Note: If a multigene panel is ordered, sequencing and array/multiplex ligation-dependent probe amplification (MLPA) tests for all
genes will be performed at the same time.
Ethnic Background
European Caucasian African American Hispanic Asian Other (specify): _________________________________
Clinical Information (check all that apply)
Polyps? Yes No Unknown/Not Screened
Number: 0 polyps 1–5 6–20 21–50 51–100 More than 500
Location: Histopathology:
Cancer
Colon Endometrial Gastric Breast Ovarian Pancreatic Brain
Upper tract urothelial Sarcoma Adrenocortical carcinoma Leukemia/Lymphoma
Thyroid, specify type: ________________________ Other, specify: _________________________________________
Dermatological features? Yes No If yes, describe: _________________________________________________________
Other Manifestations
Congenital hypertrophy Fibrocystic disease Macrocephaly Pheochromocytoma
of retinal pigment epithelium
Ganglioneuromas Oligodontia Sertoli cell or sex cord tumors
Desmoid tumors Hyperparathyroidism Osteomas Telangiectasias
Epidermoid cysts Lhermitte-Duclos disease Overgrowth Uterine fibroids
Other, specify: ________________________________________________________________________________________
Has previous testing been performed for this patient? Yes No If yes, complete information below:
Sequencing for genes: __________________________________________________________________________________
Deletion/duplication for genes: ____________________________________________________________________________
Has microsatellite instability/immunohistochemistry (MSI/IHC) been performed? Yes No
If yes, describe: __________________________________________________________________________________________
Family History
Are other relatives known to be affected? Yes No If yes, relationship to the patient: _________________________
Have other relatives had molecular genetic testing? Yes No If yes, complete the information below:
Gene: _____________________ Name and birth date of individual tested: _______________________________________________
Mutations: _______________________________ Laboratory at which testing was performed: ________________________________
Molecular Genetics: Inherited
Cancer Syndromes Patient Information
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