Gknowmix Test Request


Gknowmix Reference: Gknowmix Reference: Gknowmix Reference:

Client Details

Service Options

Please select a test type
Service Required?
Receive quote email:
Receive informed consent email:

Health Care Practitioner Information

Referring Health Professional email address
Referring Healthcare Practitioner
Contact Number
Participating HP Email Address
Copy to Participating HP
Participating HP Contact Number
Client Email Address
Client Title
Client First Name
Client Surname
Address
Post Code
Date of Birth
Age
Ethnicity
Gender
Client Contact Number
Gknowmix Reference
Histopathology Number
Specimen Identifier / Barcode
Sample request date

Consent

I hereby give consent to services requested, guarantee payment and verify that all information is correct
The laboratory is allowed to release the diagnostic codes to my medical aid if necessary
My genetic material and clinical information may be included in in a database for research, related to the services requested, without revealing my identity
After completion of the genetic test my genetic material should be handled as follows:

Medical Aid Information

Medical aid
Plan Option
Member Number
Reference / Authorization No
ICD-10 Code
Medical Aid Motivation
Include Medical Aid Motivation in Quote

PSG Information

Pre-Test Information

Clinical Diagnosis (cancer type eg. breast, sarcoma, small cell lung cancer, glioblastoma, etc.)
Tumour primary site
Diagnosis date
Age of onset
Current site of metastases
List sites of metasteses
Clinical staging at diagnosis
Previous systemic therapies
Current therapy
Relevant comorbidities
Concomitant medications
Weight kg
Height m
Body mass index (BMI) kg/m^2
Date of referral/sample provided:
Biomarkers already tested(e.g. : ER, BRCA1, MSI, MGMT, ...)
Biopsy Type:
Date of biopsy
Previous cancer diagnosis
Is the same sample that was used for the diagnosis, used for molecular tumour testing?

Post-operative

Histopathology Number(Additional Biopsy)
Biopsy (nodes):
Pathology type:
Tumor size (mm):
Multicentricity:
Pathology grade:
Estrogen Receptor:
Estrogen Receptor Intensity
Estrogen Receptor Percentage
Progesterone Receptor:
Progesterone Receptor Intensity
Progesterone Receptor Percentage
HER2-neu status using IHC:
HER2-neu status using FISH:
HER2 ratio
HER2 copy number
Ki67 (%)
Lymphovascular Invasion:
Extent of nodal metastases

Post Test Information Sheet

Status of patient
Diagnosis Event
Date of Diagnosis Event
Cause of death
Report date
Chemotherapy:
Gene mutations identified
Drugs with predicted clinical benefit
Change in planned adjuvant therapy based on genomic test
Chemotherapy Other
Endocrine Therapy
Endocrine Therapy Other
Endocrine Therapy Compliant
Anti-HER2 treatment:
Anti-HER2 treatment Other
Additional information related to treatment decision (e.g. specific side effects / radiotherapy
Treatment information above verified by clinician / oncologist
Date of verification (DD/MM/YYYY)

PSG Genetic Testing

Patient Deceased
Solid tumour biopsy mutations detected
Liquid biopsy mutations detected
OncoStrat&GO additional information
Other tests performed
Other test results
If Multiple, indicate:
Ethics waiver of consent
Research Number