Forms and Requisitions

 

To order a genetic test, please complete the following forms with your patient:

  • Requisition form
  • Consent form
  • Payment form (if applicable)
  • Provincial healthcare funding application (if applicable)

If you are located in a province other than Ontario or BC, your patient may choose to use a third-party laboratory (e.g., DynaLife (Alberta), Calgary Lab Services (Alberta), Diagnostic Services (Manitoba)), to provide samples.

Forms are reviewed and updated periodically. Review this page regularly to ensure you are using the latest versions.

If you have any questions about the tests or the ordering process, please do not hesitate to contact us.

 

Genetic Tests for Reproductive Health

Non-Invasive Prenatal Testing for Parent Preparedness
Panorama® Forms*

Panorama® is a Non-Invasive Prenatal Test (NIPT) that screens for common genetic conditions caused by extra or missing chromosomes in the baby’s DNA as early as 9 weeks. Panorama analyzes baby’s (placental) DNA through a simple blood draw from the mother’s arm.

Ordering Instructions

Mandatory Patient Consent Form (Kept in Patient File)

Requisition Forms

Payment Form

Third-Party Lab Requisitions for Sample Collection (Provinces Outside of Ontario and BC)

Requisition Change Form

*Forms last updated in August 2017

 

Genetic Carrier Screening for Family Planning

Counsyl Forms*

The Counsyl Family Prep Screen identifies parents-to-be that are likely to pass on genetic conditions to their children. Even without a family history of disease, you can still be a carrier and benefit from this test, which screens for over 175 conditions before or during pregnancy. Please note that this is NOT a prenatal screen and does not test baby’s DNA (i.e., placental or fetal DNA).

Private-Pay Payment Form for Counsyl

Mandatory Patient Consent Form

Requisition Forms

Application for Ministry Funding

Payment Form

*Forms last updated in August 2017

 

Genetic Tests for Cancer

Hereditary Breast and Ovarian Cancer (HBOC) Susceptibility Testing
BRCA1 + BRCA2 (with Genetic Counselling) Forms*

This test identifies women and men who are at an increased risk for developing certain cancers (e.g., such as breast, ovarian, fallopian tube, peritoneal, melanoma, pancreatic, and/or prostate cancer).

Mandatory Patient Consent Form

Patient Consent Form for BRCA1/2

Requisition Forms

BRCA1/2 + Counselling Requisition

Payment Form

 

*Forms last updated in August 2017

Breast Cancer Prognostic Gene Signature Assay
Prosigna® Forms*

The Prosigna® Breast Cancer Prognostic Gene Signature Assay looks at 50 genes in your cancer cells to assist in identifying the likelihood that the cancer may return over the next 10 years and aid in cancer management.

Requisition and Patient Consent Form

Requisition and Consent for Prosigna

Payment Form

Private-Pay Payment Form for Prosigna

*Forms last updated in August 2017

 

Whole Exome Sequencing and Whole Genome Sequencing

Whole Exome Sequencing (WES) CentoXome® Forms*

To determine a cause for a complex genetic disorder, CentoXome® analyzes thousands of genes simultaneously, providing an alternative to single-gene tests or multigene panels to investigate the molecular basis of genetic disorders.

Requisition and Patient Consent Form

Requisition and Consent Forms for WES

Application for Ministry Funding

MOHLTC Application Form for WES (Ontario Only)

*Forms last updated in August 2017

Whole Genome Sequencing (WGS)
CentoGenome® Forms

WGS is one of the latest genetic technologies that sequences the entire coding and non-coding regions of the genome to help provide answers for individuals with complex disease where other tests have not.

Requisition and Patient Consent Form

Please contact us to discuss your WGS needs and get the forms

*Forms last updated in August 2017

 

Genetic Tests for Hereditary Conditions

(Forms for 3500+ Genetic Tests)* 

These 3500+ diagnostic and predictive single gene and genetic panel tests provide concrete, actionable insights that lead to informed decision making and personalized treatment.
Search for a test using our Search tool to access a full range of diagnostic, predictive, carrier, and prenatal genetic tests completed at our lab in Toronto or by our partner CENTOGENE
Please use the search tool to identify the test code and name on page 2 of the requisition.

Ordering Instructions

  • Ontario

  • BC

  • Patients in other provinces and territories need to submit a requisition, consent form, and sample to LifeLabs Genetics as per the instructions in the kit.

Requisition and Patient Consent Form

Requisition and Consent Forms for Hereditary Conditions

Application for Ministry Funding

*Forms last updated in August 2017

 

Pharmacogenetics

TreatGx Plus Testing Service

TreatGx Plus predicts an individual’s response to prescription medications by analyzing medication-to-medication, medication-to-disease, and medication-to-genetic interactions. These personalized results lead to ideal drug brand and dosage combinations. The service spans  hundreds of medications and dozens of common conditions.

There are no paper-based forms for this test. Order online only. Each order includes a home collection kit to give to your patient and a subscription to the medication decision-support software.

 

How to Change a Requisition

  • Changing Genetic Testing Instructions

    At LifeLabs Genetics, we are keen to provide useful, accurate, and reliable results. If your patient’s details change and you’d like to update a requisition that you’ve already submitted, contact us. We may be able to adjust the test to meet your new requirements within the usual turnaround time or send you an altered report.

  • Changing a Panorama® Requisition

    The Panorama® non-invasive prenatal test has a specific change authorization form. If the due date changes or the parents would now like to know the baby’s gender, for example, please complete and submit this form to speed up the change process.

 

Contact Us

Genetic testing can seem complicated. Our team of certified genetic counsellors and client-care specialists are available to support you along the way.

To ensure we provide you with the correct information, please select your province.

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To ensure we provide you with the correct information, please select your province.
  • British Columbia
  • Ontario
  • Alberta
  • Manitoba
  • New Brunswick
  • Newfoundland and Labrador
  • Northwest Territories
  • Nova Scotia
  • Nunavut
  • Prince Edward Island
  • Quebec
  • Saskatchewan
  • Yukon

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