Test Requisition
Form

10222 Barnes Canyon Road, Building 1 | San Diego, CA 92121
Phone: 858.224.6650 | Fax: 858.224.6655 | www.invivoscribe.com/clinical-services
CLIA# 0501078819 / CAP# 7199699 | M-0149 Rev01 January 2024

Important Notice: LabPMM is not enrolled in the Medicare program and is unable to bill

By submitting this Test Requisition Form, the ordering entity represents and warrants that thespecimen is not for a Medicare patient and acknowledges and agrees that LabPMM will notrefund any payment made to LabPMM in the event the entity submits a Medicare patient
specimen in error.

Medicare (or Medicare supplemental insurance) for any laboratory tests, including those thatmeet the Medicare criteria set forth in the “Laboratory Date of Service for Clinical Laboratoryand Pathology Specimens” regulation (42 CFR Section 414.510(b)(5).

Received Date:
Time:

Tech:

Place patient label here if desired

Specimen Volume:
Tube/Container:
Accession #:PATIENT INFORMATIONPHYSICIAN/CLIENT INFORMATION*REQUIRED INFORMATIONName*:

Physician*:

Date of Birth*:

Institution*:

Reported Ancestry:

Address*:

Medical Record #:Gender:MMedicare #:Address 2:

F

Phone*:

GENE PANEL REQUESTEDMyAML®

*REQUIRED INFORMATION

Fax:Email:Acute Myeloid Leukemia Sequence analysis of 194 genes

ABCC1, ACVR2B, ADRBK1, AKAP13, ANKRD24, ARID2, ARID4B, ASXL1, ASXL2, ASXL3, BCOR, BCORL1, BRINP3, BRPF1, BUB1,CACNA1E, CBL, CBX5, CBX7, CDC73, CEBPA, CEP164, CPNE3, CSF1R, CSTF2, TCTCF, CYLD, DCLK1, DDX1, DDX23, DHX32,DIS3, DNAH9, DNMT1, DNMT3A, DNMT3B, DYRK4, EED, EGFR, EP300, EPHA2, EPHA3, ETV3, EZH2, FANCC, FLT3, GATA1,GATA2, GFI1, GLI1, HDAC2, HDAC3, HNRNPK, HRAS, IDH1, IDH2, IKZF1, JAK1, JAK2, JAK3, JMJD1C, KDM2B, KDM3B, KDM6A,KDM6B, KIT, KMT2B, KMT2C, KRAS, MAPK1, METTL3, MST1R, MTA2, MTOR, MXRA5, MYB, MYC, MYLK2, MYO3A, NF1,NOTCH1, NOTCH2, NPM1, NRAS, NRK, OBSCN, PAPD5, PAX5, PDGFRA, PDGFRB, PDS5B, PDSS2, PHF6, PKD1L2, PLRG1,POLR2A, PRDM16, PRDM9, PRKCG, PRPF3, PRPF40B, PRPF8, PTEN, PTPN11, PTPN14, PTPRT, RAD21, RBBP4, RBMX,RPS6KA6, SAP130, SCML2, SETBP1, SETD2, SF1, SF3A1, SF3B1, SMC1A, SMC3, SMC5, SMG1, SNRNP200, SOS1, SPEN,SRRM2, SRSF2, SRSF6, STAG2, STK32A, STK33, STK36, SUDS3, SUMO2, SUPT5H, SUZ12, TCF4, TET1, TET2, THRB, TP53,TRA2B, TRIO, TTBK1, TYK2, TYW1, U2AF1, U2AF1L4, U2AF2, UBA3, WAC, WAPAL, WEE1, WNK3, WNK4, WT1, ZBTB33, ZBTB7B,ZRSR2 | ABL1, ADGRG7, AFF1, BCR, CBFB, CREBBP, DEK, EIF4E2, ELL, ETV6, GAS6, GAS7, KAT6A, KAT6B, KMT2A, MECOM, MKL1, MLLT10, MLLT1, MLLT3, MLLT4, MYH11, NSD1, NUP214, NUP98, PICALM, PML , RARA, RBM15, RPN1, RUNX1,RUNX1T1, SEPT5, SET, TFG, TMEM255B

SPECIMEN TYPE

Peripheral Blood
2-4 mL in EDTA or Sodium Heparin

Bone Marrow
1-2 mL in EDTA or Sodium Heparin

Isolated DNA

precision hotspot panel to detect and track myeloid
MyMRD® NGS
malignancies of 23 genes

1-2 µg from EDTA or Sodium Heparin

ASXL1, BRAF, CALR, CEBPA, CSF3R, DNMT3A, FLT3, IDH1, IDH2, JAK2, KIT, KMT2A, KRAS, MPL, MYH11, NRAS, NPM1,PTPN11, RUNX1, SF3B1, SRSF2, TP53, ZRSR2Transport specimens ambient(18-25°C/64-77°F) or with cold packs
in provided packaging. If using cold
packs for transport, make surecold pack is not indirect contact withspecimen. Do not freeze. Specimens
should arrive in the laboratory
within 48 hours of collection.

SAMPLE INFORMATIONWBC count:%Blasts:

Diagnosis:

Tumor %:

Tissue Source:

ICD10 Code:

Date of Collection:

Time:

Reason for Submission:

Has the patient received an Allogenic Stem Cell Transplantation:

Yes

No

Please send all pathology and test results from all other molecular diagnostic assays.

RESEARCHLabPMM® may use your leftover specimen and your health information, including genetic information, in an anonymized, or de-identified, form (unless otherwise allowed by applicablelaw) for research and education purposes. Such uses may result in the development of commercial products and services. You will not receive notice of any specific uses and you will
not receive any compensation for these uses. All such uses will be in compliance with applicable law. You may refuse to allow LabPMM® to use your leftover specimen or information forresearch by marking the applicable box below. You may also withdraw your consent for research uses at a later date by submitting an "Opt-Out of Research Form" to the laboratory.

Opt Out of Research

Patient Signature:

Date:

LabPMM® PATIENT INFORMED CONSENT
I, the patient, certify to having the assay performed, acknowledge that:
I understand that this test is voluntary and I have had the opportunity to ask questions and discuss with my healthcare provider the risks, benefits and alternatives of this test. I have been
informed about the availability of genetic counseling and have been provided with information identifying an appropriate healthcare provider from whom I might obtain such counseling.
I have read and understand the content of this document and may have a copy if desired. These test results may impact life, disability, and long-term care insurance. I understand thatmy sample will be tested for many different genes that may have conditions that impact me and my blood relatives. The American College of Medical Genetics and Genomics (ACMG)
suggests that secondary findings be discussed with those who share these variants with me. I have considered the way to communicate this information to them.

Patient Signature:
Page 1 of 1