Form 2236 - Cytogenetics Laboratory Requisition Form
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1Cytogenetics Laboratory Requisition
Eastern Ontario Regional Genetics Program
401 Smyth Road, Rm w3401
Ottawa, ON, K1H 8L1
Tel: (613) 737-2554 Fax: (613) 738-4814
S
TAMP
(under Programs & Health Info →
Programs & Health Info (A-Z listing) → Genetics → Cytogenetics)
Patient Name:
ALL SECTIONS MUST BE COMPLETED
Last
First
Initial
Health Card Number:____________________________________
Collection Date: __________________ Time: _________
DOB: (yy/mm/dd) ______________________________________
Collection Centre:
Address:______________________________________________
CHEO Inpatient
CHEO Outpatient
_____________________________________________________
Other location (specify): ______________________
Telephone:____________________________________________
Specimen collected by: __________________________
PRINT
Gender (circle one):
Male
Female
Health Care Provider Requesting Test
Name:________________________________________
Copy to:
Name:_______________________________________________
Registration Number: ___________________________
Registration Number: __________________________________
Address: _____________________________________
Address: ____________________________________________
_____________________________________________
____________________________________________________
Telephone:____________________________________
Telephone:___________________________________________
FAX: ________________________________________
FAX: _______________________________________________
Test Requested
Refer to website (see above) for testing services available
Standard Chromosome Analysis/ Karyotype
Microarray Follow-Up FISH Custom Probe:
Proband
Family Member – Relationship to Proband:
FISH: specify probe(s) (see website for FISH tests available) ________________________________
RAD (Rapid Aneuploidy Detection)
Tissue Culture:
Frozen storage only
Shipment Only
Frozen Storage and Shipment
(please attach shipping information and appropriate documentation for external laboratory)
Other, specify: __________________________________
Collect blood specimens in a sodium heparin tube (10 mL for adults and children, 3 mL for newborns). Do not freeze or spin.
Specimen Type
Collection instructions for other specimens available on the website (see above).
Amniotic Fluid - Gestational Age: _______________
Blood
Bone Marrow
Twin/Multiple Pregnancy:
Twin A
Twin B
Solid Tissue
source : _________________________________
Fibroblasts
source : _________________________________
Chorionic Villus Sample - Gestational Age :_______________
Tumour
source : _________________________________
Other
source : _________________________________
Oncology Testing
New Diagnosis
Follow-Up
Post Bone Marrow Transplant
Relapse
Treatment:
Yes /
No
WBC____________ %Blasts__________
If peripheral blood please provide:
Other, specify ________________________
Analysis cannot be performed unless appropriate clinical and/or family history is provided.
Clinical Indication & Comments
LABORATORY USE ONLY
Sample size: __________mL or mg
Lab#_________________
Fluid Quality:
Clear
Cloudy
Slight Blood
Gross Blood
Discoloured
Pellet Quality:
Normal
Tissue
Bloody
Ped#_________________
Pellet Size: S
M
L
Villi:
Typical
Atypical
Absent
Form No. 2236, April 2015
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