VIRGINIA OBSTETRICS & GYNECOLOGY, P.C.

Transcription

1

2 VIRGINIA OBSTETRICS & GYNECOLOGY, P.C Sandridge Way Suite 350 Leesburg, VA Phne (703) Fax (703) PERSONAL INFORMATION: PATIENT INFORMATION SHEET Please Print Date. Patient's Name Date f Birth SSN First MIi Last Address Sire el City Stale Zip Marital Status: S M Sep W D Hme Phne Cell Phne. , Emplyer Occupatin. Emplyer's Address Spuse's Name Wrk Phne Wrk Phne. Emergency Cntact. Relatin t Patient Phne Referred by INSURANCE INFORMATION: Primary Insurance C.. Effective Date. Address Phne Plicyhlder's Name. Relatin t Patient. Member ID # Grup # Plicyhlder Date f Birth Secndary Insurance C.. Effective Date Address Phne Plicyhlder's Name Relatin t Patient. Member ID # Grup # Plicyhlder Date f Birth PERSON RESPONSIBLE FOR PAYMENT OR INSURANCE POLICYHOLDER (IF OTHER THAN PATIENT): Legal Name Relatin t Patient First Ml Las I Address Phne Date f Birth Street Crty Stale Zip Sex: M F Marital Status: S M Sep W D Emplyer's Name Emplyer's Address Occupatin Wrk Phne PATIENT CONSENT, AGREEMENT OF FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS: I, the undersigned, cnsent t the use and disclsure f my prtected health infrmatin fr treatment, payment and peratins and such ther purpses that are permitted under the federal Health Insurance Prtability and Accuntability Act withut a written authrizatin. I accept that I am financially respnsible fr all services rendered n my behalf by Virginia Obstetrics & Gyneclgy, P.C. (the Practice). Fr thse insurance plans fr which the Practice accepts assignment, I accept persnal respnsibility fr all c-payments, deductibles and nn-cvered services, as dictated by my insurance cverage, plus any cllectin csts fr amunts persnally wed by me, including attrney fees if necessary. I authrize payment directly t the Practice fr services fr which the Practice accepts assignment. A cpy f this agreement may be used in place f the riginal. I certify that the infrmatin stated n this frm is crrect. Signature f Patient r Parent/Legal Guardian Date (Rev.6,119)

3

4

5

6

7 Hereditary Cancer Questinnaire (t be cmpleted by patients) Patient Name: Date f Birth: Tday s Date: Instructins: This is a screening tl t help yur healthcare prvider determine if yu wuld benefit frm hereditary cancer genetic testing. Yur healthcare prvider will review this frm lking fr any risk factrs fr a hereditary cancer syndrme such as similar types f cancer running in the family, cancers diagnsed at yung ages, r multiple cancer diagnses in the same persn. des cancer run in yur family? check thse that apply. Please fill this frm ut t the best f yur ability. Please nly cnsider family members related t yu by bld, such as yur parents, grandparents, children, brthers, sisters, aunts, uncles, and cusins. If yu share nly ne parent with a brther r sister, please indicate that. ü TYPE OF EXAMPLE: Clrectal Cancer BREAST (in wmen r men) OVARIAN (peritneal/ fallpian tube) UTERINE (ENDOMETRIAL) COLORECTAL YOURSELF/PARENTS/ BROTHERS/ SISTERS/CHILDREN AGE AT DIAGNOSIS (estimates are OK) EXTENDED FAMILY (MOTHER S SIDE) Aunts/Uncles/Cusins/ Grandparents /Other AGE AT DIAGNOSIS (estimates are OK) Me 42 Aunt Uncle EXTENDED FAMILY (FATHER S SIDE) Aunts/Uncles/Cusins/ Grandparents /Other AGE AT DIAGNOSIS (estimates are OK) PANCREATIC KIDNEY (RENAL) OTHER Type: OTHER Type: OTHER Type: MORE THAN 10 COLORECTAL POLYPS (indicate hw many) My family s heritage is Ashkenazi Jewish (an ethnic backgrund that may have a higher likelihd f hereditary cancer) I, r smene in my family, have had genetic testing fr a hereditary cancer syndrme. (Please describe and prvide a cpy f result if pssible) 1

8 Pssible Indicatins fr Genetic Testing and Ptential Testing Optins* (t be cmpleted by healthcare prvider) weighing the ptins: Single Syndrme Testing: These tests are targeted, analyzing ne gene r syndrme at a time, and are ften chsen if the patient/family is highly suspicius fr ne gene/syndrme and/r desires the lwest pssible VUS rate. High Risk Panel: These tests simultaneusly analyze multiple well-described genes with published management guidelines, and are ften chsen if the patient/family is suspicius fr multiple syndrmes and/r nly wants t be tested fr genes with published management guidelines. Cmprehensive Panel: These tests are mre cmprehensive and prvide the greatest chance f identifying a mutatin. They can be tumr-specific r general. Since there are mre genes n these tests, the VUS rates are higher and sme genes d nt have published management guidelines. PATIENT S PERSONAL & FAMILY HISTORY SINGLE SYNDROME TESTS HIGH RISK PANELS COMPREHENSIVE PANELS Hereditary Breast Cancer Early nset breast cancer (<45, <35 fr TP53) Multiple primary cancers in ne persn (e.g. tw primary breast cancers r breast and varian cancer) Breast cancer in an Ashkenazi Jewish individual, triple negative breast cancer <60, r breast cancer in a man Multiple clse family members with breast and/r ther cancers** Hereditary Gyneclgic Cancer Ovarian, fallpian tube, r primary peritneal cancer at any age Uterine cancer <50 r with abnrmal MSI/IHC Multiple clse family members with varian r uterine, and ther cancers** Multiple primary cancers in ne persn (e.g. uterine and breast r clrectal cancer) Hereditary Clrectal Cancer >10 clrectal plyps in an individual Clrectal cancer <50 r with abnrmal MSI/IHC Multiple clse family members with cln, uterine, varian, and/ r stmach cancer** Multiple primary cancers in ne persn (e.g. tw primary clrectal cancers r clrectal and uterine cancer) Hereditary Pancreatic Cancer Pancreatic cancer <60 Multiple primary cancers in ne persn (e.g. pancreatic and melanma) Multiple clse family members with pancreatic and/r ther cancers** Hereditary Kidney Cancer Kidney cancer <45 Multiple primary kidney cancers Multiple clse family members with kidney r ther cancers** Hereditary PGL/PCC BRCA1/BRCA2, TP53 BRCA1/BRCA2 BRCA1/BRCA2, Lynch syndrme^ Lynch syndrme^ APC, MUTYH Lynch syndrme,^ APC, MUTYH Lynch syndrme,^ BRCA1/BRCA2, PALB2, CDKN2A VHL BRCAplus GYNplus BreastNext, CancerNext OvaNext, CancerNext ClNext, CancerNext PancNext, CancerNext RenalNext, CancerNext- Expanded Phechrmcytma r paraganglima at any age SDHx,^^ RET PGLNext, CancerNext-Expanded Other Hereditary Cancers Multiple types f tumrs in ne persn r in a family, which are suspicius fr mre than ne syndrme CancerNext, CancerNext- Expanded *This list f testing indicatins is nt cmprehensive and the testing ptins are suggestins. There are ther situatins nt listed where genetic testing may be apprpriate and ther genes and tests available at ambrygen.cm. **On the same side f the family ^Lynch syndrme is caused by mutatins in the MLH1, MSH2, MSH6, PMS2, and EPCAM genes ^^SDHx includes SDHAF2, SDHB, SDHC, and SDHD _v1 15 Argnaut, Alis Viej, CA Tll Free Fax ambrygen.cm 2