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Genomic Medicine Service
Whole Genome Sequencing (WGS) Test Request
PLEASE DO NOT USE FOR NON-WGS TESTS
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| Requesting organisation: [% r.patient_case.referral_source.display_name %] | |
| GLH laboratory to receive sample: | Test Required Whole Genome Sequencing |
| Patient first name: [% patient.first_name.ucfirst %] |
Ethnicity (Please tick on page 2)
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| Patient last name: [% patient.last_name.upper %] |
Test Directory Clinical Indication & code
(cancer type and reason for testing)
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Date of birth [% patient.dob.dmy('/') %] |
Hospital number
[% r.patient_case.unit_number %]
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Gender
Male
Female
Other / Unknown
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NHS number (or postcode if not known)
[% INCLUDE site/nhs_number.tt
nhs_number = patient.nhs_number; %]
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Presentation status
First diagnosis
Recurrence/relapse
Unknown
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Additional clinical information (if relevant)
eg previous tumours, molecular testing,
and relevant treatment history with dates
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| Solid tumour requests only | ||
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Primary
Metastatic
Lymphoma
Unknown
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Histopathology lab ID
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Additional tumour information (if relevant)
eg site of metastasis (if metastatic), or
unknown primary
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Date of diagnosis
dd/mm/yyyy
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| Haemato-oncology liquid tumour requests only | ||
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| AML ALL Other (please specify) |
Local sample ID
[% UNLESS germline; INCLUDE site/lab_number.tt data = r;
END %]
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Date of diagnosis dd/mm/yyyy
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| Complete for tumour samples | ||||
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| Fresh tissue Bone marrow Peripheral blood Other (please specify): | ||||
| Provide % malignant nuclei / blasts or equivalent in this sample (refer to sample handling guidance) | ||||
| Local sample tube ID | Collection date / time | % malignant nuclei / blasts | nucleated cell count | volume required |
| x109/L | µL | |||
| Complete for germline samples | |||
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| Peripheral blood Saliva Fibroblasts Skin biopsy Other (please specify): | |||
| Local sample ID | Collection date / time | Sample volume if applicable | Comments |
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[% IF germline;
INCLUDE site/lab_number.tt data = r; END %]
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| Consultant details | |
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Responsible consultant:
[% r.referrer_department.referrer.name %]
Department:
[% r.referrer_department.hospital_department.display_name %]
Phone:
Email:
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Main contact (if different from responsible consultant)
Name:
Department:
Phone:
Email:
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I have attached a copy of the Record of Discussion form
Patient conversation taken place, Record of Discussion form to follow