To be filled in by physician please - CENTOGENE

Chief Medical Director:
Prof. Arndt Rolfs, MD
Centogene GmbH
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
FN319279d, Corporate Registry Wien
Biochemical Requisition Form Rev. 11
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: ........................ (d/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:
E – EDTA blood S – Serum P – Plasma L – Liquor/CSF U – Urin D – Dried Blood
Clinical Symptoms:
Tentative 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 Psychomotorical 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 anamnesis: yes no
(Please list) ........................................................ (Pedigree data to be attached in separate document)
Requesting Physician:
Name: …………………………… Phone: ………………………
Date / signature: ………………………
Contact:
Head of Laboratory: A. Mühl, PhD adolf.muehl@centogene.com
Med. Consultant: M. Holub, MD margareta.holub@centogene.com page 1 of 2

Address for dispatch of samples:
Centogene GmbH
Schillingallee 68
18057 Rostock
Germany
Request (for molecular genetics please download the request form from www.centogene.com)
1. Basic-Metabolic Diagnostics:
consits of analysis of:: organic acids/Urine 4 , acylcarnitines/dried blodd 6 , amino acids/plasma 2 , MPS/urine 4
2. Amino acid metabolism
Amino acids: (E) 2 ; (D) 6 ; (U) 4 ; (L) 1 Homocysteine (P or 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 Sulfatides* (U) 8 Purines/Pyrimidines (U) 4
Orotic acid (U) 4 Organic acids (U) 4
5. Special tests BLOOD
CDG-Diagnostic* (E) 2 Pipecolic acid (E) 2 Total galactose (D) 6 Guanidinoacetate (D oder E) 6,2
Phytanic acid* (E) 2 Very long chain fatty acids* (E) 2 Succinylacetone (D) 6
6. Lysosomale enzymes
Screening of lysosomale storage disoders: M. Fabry, Gaucher, Krabbe, Niemann-Pick, Pompe, Hurler (MPS-I) 7
α-Fucosidase (E, D*, S) 2,6,1 MLD; Arylsulfatase A (E) 4
α-Mannosidase (E, D*, S) 2,6,1 MPS-I; α-Iduronidase (D or E) 6,2
GM1-Gangl./MPS IVB; β-Galactosidase (E, D*, S) 2,6,1 MPS-II; α-Iduronatsulfatase (D, E) 6,2
MPS VII; β-Glucuronidase (E, D*, S) 2,6,1 MPS-III a-d (E) 3
Fabry; α-Galactosidase (T or E) 6,2 Pompe; α-Glukosidase (D oder E) 6,2
Gaucher; β-Glucosidase (T or E) 6,2 Niemann Pick A/B; Sphingomyelinase (D or E) 6,2
GM2-Gangl.; Total-Hexosaminidase (E or T*) 6,2 PPT / NCL1* (E, D) 2,6
GM2-Gangl.; Hexosaminidase A (E or T*) 6,2 TPP / NCL2* (E, D) 2,6
Krabbe; β-Galaktocerebrosidase (T or E) 6
7. Sterol metabolism
17-OH Progesterone (T) 6 Bile acid metabolites* (U) 5
Dehydrocholesterole-(Smith Lemli Opitz Syn.) (E) 2 Total bile acids* (E oder S) 2
8. Biomarker / miscellaneous
Lyso-Gb-3, Biomarker (Fabry) (D or E) 6,2
Lyso-Glucosylsphingosine (L-Gb1), Biomarker (Gaucher) (D or E) 6,2
Nieman-Pick, Sphingosylphosphorylcholine + Derivat e 509 (D) 6
9. Other enzymes
Biotinidase (D) 6 Galactose-1P-uridyltransferase (D) 6
10. Newborn-Screening (patients age max 4 weeks)
Newborn-Screening (D) 7 (please call for additional information:: +43 (0) 1 798 50 06 300)
Minimal amount of sample material per anaylsis:
1) 0, 5 ml 4 ) 5 ml 7) 3 Circles
2) 1 ml 5) 10 ml 8) Total amount of urine per 24 h
3) 2 ml 6) 1 Circle
*Analysis done by external laboratory
Material of sample sent-in remains property of patient. Excessive material of sample will be stored up to max. approx. 2 months – up
to this date further analytics can be requested or remaining material sent back.
Contact:
Head of Laboratory: A. Mühl, PhD adolf.muehl@centogene.com
Med. Consultant: M. Holub, MD margareta.holub@centogene.com page 2 of 2