Request Form - CENTOGENE

Chief Medical Director:
Technical supervision:
Medical counseling:
Prof. Arndt Rolfs, MD
Dr. Adolf Mühl
Dr. Margareta Holub, MD
Centogene AG
Place of Business Rostock
Schillingallee 68
18057 Rostock
Germany
Tel.: +49 (0)381 20365 10
Fax: +49 (0)381 203652 19
Mail: office@centogene.com
Web: www.centogene.com
Biochemical Requisition Form Rev. 14
Please fill out all the red-marked/italicized fields with special care.
Patient Data (or sticker)
Physician Data (hospital/clinic stamp)
Last Name: ....................................... Physician’s Name: .....................................
First Name: ....................................... Hospital/Dep: ..........................................
Mailing address: .................................. Mailing address: .......................................
Zip-code/City: .................................... Zip-code/City: .........................................
Date of birth: ........................ (dd/mm/yyyy) Phone: ...................................................
Sex: ❏m ❏w Fax: ......................................................
E-Mail: ...................................................
Date of sampling: ...............................
Time of sampling: ............................... Submit copy of report by e-mail: ❏yes ❏no
Name of sample taker........................... Invoice to: ❏Patient ❏Clinic/Hospital
Sample type:
If invoice will be paid by patient directly, we need the
signature of the patient or his/her parents
Signature of the patient or parents ………………………...
❏E – EDTA blood ❏S – Serum ❏P – Plasma ❏L – CSF ❏U – Urine ❏D – Dried blood spot
Clinical Symptoms:
Diagnosis:
To be filled in by physician please
(A detailed medical history is an important prerequisite to an adequate analysis)
Hypoglycaemia: ❏yes ❏no Metabolic acidosis: ❏yes ❏no
Hyperammonaemia: ❏yes ❏no Muscular hypotonia: ❏yes ❏no
Epilepsy: ❏yes ❏no Psychomotor retardation: ❏yes ❏no
Hepatopathy: ❏yes ❏no CK-increase: ❏yes ❏no
Medication: ❏yes ❏no Infusion: ❏yes ❏no
(Please list) ......................................................... (Please list) ..................................................
Special diet: ❏yes ❏no Positive family history: ❏yes ❏no
(Please list) ........................................................ (Pedigree data to be attached in separate document)
Requesting Physician:
Date / signature: ……………………………..
Contact:
Technical supervision: A. Mühl, PhD adolf.muehl@centogene.com
Medical consultant: M. Holub, MD margareta.holub@centogene.com page 1 of 2

Request (for molecular genetics please download the request form from www.centogene.com)
1. Basic-metabolic diagnostics:
Address for dispatch of samples:
Centogene AG
Place of Business Rostock
Schillingallee 68
18057 Rostock
Germany
❏ Analysis of organic acids/urine 4 , acylcarnitines/dried blood 6 , amino acids/plasma 2 , MPS/urine 4
2. Amino acid metabolism
Amino acids: ❏(E) 2 ; ❏(D) 6 ; ❏(U) 4 ; ❏(L) 1 ❏Homocysteine (P, E; cooled) 3 ❏Phenylalanine (D) 6
3. Fatty acid metabolism
❏Acylcarnitines (preferably D but also E) 6,2
4. Special tests URINE
❏Guanidinoacetate (U) 4 ❏Pipecolic acid (U) 4 ❏Creatine / Creatinine (U) 4 ❏Mucopolysaccharides (U) 4
❏Succinylacetone (U) 4 ❏Oligosaccharides (U) 5 ❏Orotic acid (U) 4 ❏Organic acids (U) 4
5. Special tests BLOOD
❏ Pipecolic acid (E) 2 ❏ Total galactose (D) 6 ❏ Guanidinoacetate (D or E) 6,2 ❏ Succinylacetone (D) 6
6. Lysosomal enzymes
❏ Screening of lysosomal storage disorders: Fabry, Gaucher, Krabbe, Niemann-Pick A/B, Pompe, Hurler (MPS-I) disease 7
❏α-Fucosidase (E, S) 2,1 ❏MLD; Arylsulfatase A (E) 4
❏α-Mannosidase (E, S) 2,1 ❏MPS-I; α-Iduronidase (D, E) 6,2
❏GM1-Gangliosidosis/MPS IVB; β-Galactosidase (E) 2 ❏MPS-II; α-Iduronatsulfatase (D, E) 6,2
❏MPS VII; β-Glucuronidase (E, S) 2,1 ❏MPS-III a-d (E) 3
❏Fabry; α-Galactosidase (D, E) 6,2 ❏Pompe; α-Glucosidase (D, E) 6,2
❏Gaucher; β-Glucosidase (D, E) 6,2 ❏Niemann-Pick A/B; Sphingomyelinase (D, E) 6,2
❏GM2-Gangliosidosis; total hexosaminidase (E) 2 ❏GM2-Gangliosidosis; Hexosaminidase A (E) 2
❏Krabbe; β-Galactocerebrosidase (D, E) 6
7. Sterol metabolism
❏17OH-Progesterone (D) 6 ❏Dehydrocholesterole (Smith-Lemli-Opitz syndrome) (E) 2
8. Biomarker
❏Fabry disease (lyso-Gb3) (D, E, P, S)
❏Gaucher disease (lyso-Gb1) (D, E, P, S)
❏Niemann-Pick A/B/C (Sphingosylphosphorylcholine + derivate 509) (D, E, P, S)
9. Other enzymes
❏Biotinidase (D) 6 ❏Galactose-1P-uridyltransferase (D) 6
10. Newborn-Screening
❏Newborn-Screening (D) 7 (please call for additional information: +43 (0) 1 798 50 06 300)
Minimal amount of sample material per analysis: (see numbers after each analysis)
1) 0, 5 ml 4 ) 5 ml 7) 3 Circles
2) 1 ml 5) 10 ml
3) 2 ml 6) 1 Circle
Contact:
Technical supervision: A. Mühl, PhD adolf.muehl@centogene.com
Medical consultant: M. Holub, MD margareta.holub@centogene.com page 2 of 2