Molecular Genetics: Inherited Cancer Syndromes …

Reason for TestingStudy Purpose: Diagnostic PresymptomaticIf more than one test is ordered, should all tests be performed at the same time? No YesIf no, indicate preferred order of testing: _____Note: If a multigene panel is ordered, sequencing and array/MLPA tests for all genes will be performed at the same 2015 Mayo Foundation for Medical Education and Research MC1235-98rev1115 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 the Molecular Genetics Laboratory Name (Last, First, Middle)Birth Date (Month DD, YYYY)Gender Male FemaleReferring Physician (Last, First)PhoneFax* genetic CounselorPhoneFax**Fax number provided must be from a fax machine that complies with applicable HIPAA InformationMolecular Genetics: Inherited Cancer Syndromes Patient InformationFamily HistoryAre other relatives known to be affected?

Title: MML - Molecular Genetics Inherited Cancer Syndromes - Patient Information Sheet - MC1235-98 Subject: MML - Molecular Genetics Inherited Cancer Syndromes - Patient Information Sheet - Molecular Genetics Inherited Cancer Syndromes Patient Information accurate interpretation reporting genetic results contingent reason

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  Information, Patients, Syndrome, Molecular, Genetic, Cancer, Inherited, Molecular genetics, Inherited cancer syndromes, Molecular genetics inherited cancer syndromes patient information

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