Provincial Laboratory Medicine Services Out-of-Province & Out-of-Country Laboratory or Genetic Test Funding Request
Genetic Test Application
Patient Information
All fields must be completed with sufficient detail to ensure a timely decision. All applications require signed patient consent. Incomplete applications or applications without signed consent will be cancelled. Include details and results of all relevant in-province testing completed or in progress. Where appropriate attach a consult note to provide more clinical details and context. A consult note submitted without an application lacking sufficient detail will be cancelled. For more information please refer to our website: https://www.phsa.ca/plms/forms-test-information/out-of-province-out-of-country-test-request-forms
* Application Date
* Last Name
* First Name
Middle Name
* Sex
Select...
M
F
X
U
* PHN
* Date of Birth (MM-DD-YYYY)
* City
* Testing On
Select...
Beneficiary
Fetus (current pregnancy)
Deceased Previous Pregnancy
Deceased Relative
Date of Demise (MM/DD/YYYY)
Deceased Relative: Name and PHN
Deceased Relative: Date of Death
Referring Practitioner Information
* Last Name
* First Name
* Specialty
* MSP Number
* Address
* City
* Province
Select...
BC
AB
SK
MB
ON
QC
NL
NB
NS
PE
YT
NT
NU
* Postal Code
* Email
* Phone Number
* FAX Number for Decision Letter
Genetic Counselor Name
Genetic Counselor Email
Specialist consulted
* Name of BC laboratory physician consulted on this application
Request Information
* Clinical Diagnosis/Differential Diagnosis
Rapid Review Required
Select...
Acutely ill / deteriorating rapidly
Current pregnancy
Positive Newborn Screen
Gestational Age
Expected Delivery Date (MM/DD/YYYY)
* Test Requested (Full test name, no abbreviations)
Preferred Testing Laboratory
* Specimen Type
Select...
Blood
Buccal
Saliva
Urine
DBS
Direct CVS or Amniocytes
Cell culture/Extracted DNA
Tissue
Tissue: Specify
* Explain why this test is required including how the suspected syndrome/condition/disease is treatable other than symptom management or supportive care
* Relevant Family History
* Explain in detail how the test result will significantly alter current treatment
* Details of any consanguinity
* List all testing, including genetic and non-genetic, under consideration, completed, prerequisite and in-progress relevant testing including results
* Has any biological family member had genetic testing?
Select...
Yes
No
Biological Relationship
Result
Report Date (MM/DD/YYYY)
Testing Lab
If Tested Through OOP/OOC: Name or PHN or Application #
By signing, I confirm that the above information thoroughly and accurately presents this patient’s medical need for testing.
* Referring Practitioner Signature
* Date of Signature (MM-DD-YYYY)
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