Cytogenetics Requisition Form - Prenatal
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1PATIENT INFORMATION (PLACE LABEL HERE or TYPE)
Last Name:
First Name:
MRN:
Visit #:
CYTOGENETICS LABORATORY
Date of Birth:
Division of Diagnostics Medical Genetics
Address:
Pathology and Laboratory Medicine,
Room 6-210, 600 University Avenue,
Gender: Male
Female
Unknown
Toronto, Ontario, Canada, M5G 1X5
Health Card # & Version Code:
Province
Tel: (416) 586-5304
CYTOGENETICS REQUISITION - PRENATAL
-
MSH Clinic (if applicable):
Fax: (416) 586-8882
REPORTING INFORMATION
Physician/Midwife ______________________________________
Additional Report Recipient ______________________________
Institution
__________________________________________
Institution
__________________________________________
Address
__________________________________________
Address
__________________________________________
__________________________________________
__________________________________________
Phone
________________
Fax _________________
Phone
________________
Fax _________________
E-mail
__________________________________________
E-mail
__________________________________________
PATIENT FAMILY HISTORY
Clinical information / pedigree:
Has this patient had previous cytogenetics testing?
No
Yes
Don’t Know
Have other relatives had cytogenetics testing?
No
Yes
Don’t Know
Relationship to Patient: __________________________________
DOB: _____________________ MRN: _______________________
If cytogenetics testing was previously done, please attach a copy of original report
SAMPLE INFORMATION & TEST REQUIRED
CLINICAL INDICATION
SPECIMEN INFORMATION
REASON FOR REFERRAL
Date sample collected ______________________ Gestation: ________________
Alloimmunization
Specimen Type Submitted
Carrier of Genetic Condition
Amniotic Fluid
Fetal Urine
Fetal Ultrasound Findings (specify below)
Ascites Fluid
Pleural Effusion
Late Maternal Age
Cystic Hygroma Fluid
Chorionic Villi (CVS)
Multiple Pregnancy (specify Fetus ID below)
Fetal Blood (Cordocentesis)
[Blood in EDTA (lavender
top)]
Previous Child/Pregnancy Abnormality (specify below)
Prenatal Screening (specify result details below;
include report if
applicable)
Maternal Blood for MCC
[Blood in EDTA (lavender
top)]
TTTS (Twin to Twin Transfusion Syndrome)
DETAILS:
TEST REQUIRED
Aneuploid Screen
Microarray
DNA banking
Send-out Test – Indicate Specimen Requirements
attach appropriate paperwork, instructions, waybill and pre-paid account #
Amniotic Fluid - Volume ________________________________________
Chorionic Villi - Volume ________________________________________
Cultured Cells - # T25 flasks _____________________________________
DNA – retrieve for send-out – Volume _____________________________
SPECIMEN REQUIREMENTS
Prenatal specimens for Aneuploid screen & Microarray:
Amniotic fluid: 20 to 30cc
CVS*: 10 to 15mg
*3 to 5mL of maternal
blood in EDTA minimum vol 3 ml
(lavender tube) must accompany all CVS Specimens [for Maternal Cell Contamination (MCC)
Testing]
INSTRUCTIONS FOR SUBMISSION OF SPECIMENS
Deliver specimens by 4:00pm to:
Pathology & Laboratory Medicine Rapid Response Laboratory ATTENTION CYTOGENETICS LABORATORY
th
600 University Avenue | 6
Floor, Room 6-308 | Toronto, Ontario, Canada M5G 1X5
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