VIRGINIA OBSTETRICS & GYNECOLOGY, P.C. Phone (703) 858-5599 Fax (703) 858-5699

PATIENT INFORMATION SHEET Please Print

PERSONAL INFORMATION: Date. _____________ _

Patient's Name ___________________ Date of Birth ______ SSN ______ _ First MIi Last

Address ______________________________________ _ Sire el City Stale Zip

Marital Status: S M Sep W D Home Phone _______ Cell Phone. ________ Email, ________ _

Employer ______________________ Occupation. ____________ _

Employer's Address Work Phone ____________ _

Spouse's Name Work Phone. ____________ _

Emergency Contact. ___________ Relation to Patient _________ Phone ________ _

Referred by

INSURANCE INFORMATION:

Primary Insurance Co .. __________________ Effective Date. ____________ _

Address Phone ______________ _

Policyholder's Name. ___________________ Relation to Patient. __________ _

Member ID # ___________ Group # _________ Policyholder Date of Birth ________ _

Secondary Insurance Co .. __________________ Effective Date ___________ _

Address Phone ______________ _

Policyholder's Name ___________________ Relation to Patient. __________ _

Member ID # ___________ Group # ________ Policyholder Date of Birth ________ _

PERSON RESPONSIBLE FOR PAYMENT OR INSURANCE POLICYHOLDER (IF OTHER THAN PATIENT):

Legal Name Relation to Patient First Ml Las I

Address Phone Street Crty Stale Zip

Date of Birth Sex: M F Marital Status: S M Sep W D

Employer's Name Occupation

Employer's Address Work Phone

PATIENT CONSENT, AGREEMENT OF FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS: I, the undersigned, consent to the use and disclosure of my protected health information for treatment, payment and operations and such other purposes that are permitted under the federal Health Insurance Portability and Accountability Act without a written authorization. I accept that I am financially responsible for all services rendered on my behalf by Virginia Obstetrics & Gynecology, P.C. (the Practice). For those insurance plans for which the Practice accepts assignment, I accept personal responsibility for all co-payments, deductibles and non-covered services, as dictated by my insurance coverage, plus any collection costs for amounts personally owed by me, including attorney fees if necessary. I authorize payment directly to the Practice for services for which the Practice accepts assignment. A copy of this agreement may be used in place of the original. I certify that the information stated on this form is correct.

Signature of Patient or Parent/Legal Guardian Date (Rev.6,119)

19490 Sandridge Way Suite 350 Leesburg, VA 20176

1

Hereditary Cancer Questionnaire (to be completed by patients)

does cancer run in your family? check those that apply.Please fill this form out to the best of your ability. Please only consider family members related to you by blood, such as your parents, grandparents, children, brothers, sisters, aunts, uncles, and cousins. If you share only one parent with a brother or sister, please indicate that.

TYPE OF CANCER

YOURSELF/PARENTS/BROTHERS/ SISTERS/CHILDREN

AGE AT DIAGNOSIS

(estimates are OK)

EXTENDED FAMILY (MOTHER’S SIDE) Aunts/Uncles/Cousins/Grandparents /Other

AGE AT DIAGNOSIS

(estimates are OK)

EXTENDED FAMILY (FATHER’S SIDE) Aunts/Uncles/Cousins/Grandparents /Other

AGE AT DIAGNOSIS

(estimates are OK)

o EXAMPLE:Colorectal Cancer

Me 42 AuntUncle

4655

o BREAST CANCER(in women or men)

o OVARIAN CANCER(peritoneal/ fallopian tube)

o UTERINE (ENDOMETRIAL) CANCER

o COLORECTAL CANCER

o PANCREATIC CANCER

o KIDNEY (RENAL) CANCER

o OTHER CANCERType:

o OTHER CANCERType:

o OTHER CANCERType:

o MORE THAN 10 COLORECTAL POLYPS(indicate how many)

o My family’s heritage is Ashkenazi Jewish (an ethnic background that may have a higher likelihood of hereditary cancer)

o I, or someone in my family, have had genetic testing for a hereditary cancer syndrome. (Please describe and provide a copy of result if possible)

Instructions: This is a screening tool to help your healthcare provider determine if you would benefit from hereditary cancer genetic testing. Your healthcare provider will review this form looking for any risk factors for a hereditary cancer syndrome such as similar types of cancer running in the family, cancers diagnosed at young ages, or multiple cancer diagnoses in the same person.

Patient Name:

Date of Birth:

Today’s Date:

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50339.2124_v1 215 Argonaut, Aliso Viejo, CA 92656 Toll Free 866 262 7943 Fax 949 900 5501 ambrygen.com

PATIENT’S PERSONAL & FAMILY HISTORY SINGLE SYNDROME TESTS HIGH RISK PANELS

COMPREHENSIVE PANELS

Hereditary Breast Cancer

o Early onset breast cancer (<45, <35 for TP53) BRCA1/BRCA2, TP53

BRCAplus BreastNext, CancerNext

o Multiple primary cancers in one person (e.g. two primary breast cancers or breast and ovarian cancer)

BRCA1/BRCA2o Breast cancer in an Ashkenazi Jewish individual, triple negative breast cancer <60, or breast cancer in a man

o Multiple close family members with breast and/or other cancers**

Hereditary Gynecologic Cancer

o Ovarian, fallopian tube, or primary peritoneal cancer at any age BRCA1/BRCA2, Lynch syndrome^

GYNplus OvaNext, CancerNext

o Uterine cancer <50 or with abnormal MSI/IHC

Lynch syndrome^o Multiple close family members with ovarian or uterine, and other

cancers**

o Multiple primary cancers in one person (e.g. uterine and breast or colorectal cancer)

Hereditary Colorectal Cancer

o >10 colorectal polyps in an individual APC, MUTYH

ColoNext, CancerNext

o Colorectal cancer <50 or with abnormal MSI/IHC

Lynch syndrome,^ APC, MUTYHo Multiple close family members with colon, uterine, ovarian, and/

or stomach cancer**

o Multiple primary cancers in one person (e.g. two primary colorectal cancers or colorectal and uterine cancer)

Hereditary Pancreatic Cancer

o Pancreatic cancer <60

Lynch syndrome,^ BRCA1/BRCA2, PALB2, CDKN2A PancNext, CancerNext

o Multiple primary cancers in one person (e.g. pancreatic and melanoma)

o Multiple close family members with pancreatic and/or other cancers**

Hereditary Kidney Cancer

o Kidney cancer <45

VHL RenalNext, CancerNext-Expandedo Multiple primary kidney cancers

o Multiple close family members with kidney or other cancers**

Hereditary PGL/PCC

o Pheochromocytoma or paraganglioma at any age SDHx,̂ ^ RET PGLNext, CancerNext-Expanded

Other Hereditary Cancers

o Multiple types of tumors in one person or in a family, which are suspicious for more than one syndrome

CancerNext, CancerNext-Expanded

*This list of testing indications is not comprehensive and the testing options are suggestions. There are other situations not listed where genetic testing may be appropriate and other genes and tests available at ambrygen.com. **On the same side of the family ^Lynch syndrome is caused by mutations in the MLH1, MSH2, MSH6, PMS2, and EPCAM genes ^^SDHx includes SDHAF2, SDHB, SDHC, and SDHD

Possible Indications for Genetic Testing and Potential Testing Options* (to be completed by healthcare provider)

weighing the options:• Single Syndrome Testing: These tests are targeted, analyzing one gene or syndrome at a time, and are often chosen if the patient/family is highly

suspicious for one gene/syndrome and/or desires the lowest possible VUS rate.• High Risk Panel: These tests simultaneously analyze multiple well-described genes with published management guidelines, and are often chosen if the

patient/family is suspicious for multiple syndromes and/or only wants to be tested for genes with published management guidelines.• Comprehensive Panel: These tests are more comprehensive and provide the greatest chance of identifying a mutation. They can be tumor-specific or

general. Since there are more genes on these tests, the VUS rates are higher and some genes do not have published management guidelines.