Prenatal Microarray Requisition Form printable pdf download

Acct # _________________________________________________

Last Name: _____________________________________________

First Name: _____________________________________________

DOB: ______________________(DD/MM/YYY) Sex: ___________

Healthcard #: _______________________________ VC: _________

PRENATAL MICROARRAY REQUISITION

Address: ________________________________________________

________________________________________________________

GENETICS LABORATORY

2200 Eglinton Ave. W., Rm 2H144

Tel: (905) 813-1100 x6288

Primary Phone #: _________________________________________

Mississauga, ON L5M 2N1 Canada

Fax: (905) 813-3854

Unit # __________________________________________________

To ensure there is no delay in reporting results; please ensure the following accompany each sample:

Completed requisition form

Parental samples. Mother’s sample is mandatory for MCC studies. Father’s sample is highly recommended

(Complete a Separate Prenatal Microarray Requisition for each parent)

PHYSICIAN INFORMATION

Referring Dr: ______________________________________

Copy To:_________________________________________

Registration #:_____________________________________

Address: _________________________________________

Address:_________________________________________

Telephone:__________________ Fax:__________________

Telephone:__________________ Fax:_________________

Signature (required): ________________________________

CLINICAL INFORMATION

SPECIMEN TYPE

Gestation at collection date: ________________weeks

Direct CVS (10-15 mg cleaned villi)

Karyotype result (if known) : __________________________

Cultured CVS (1 T75 or 2 T25 flasks 70% confluent)

Sex of Fetus (if known): ______________

Direct Amniotic Fluid (15cc)

(by

QF-PCR

FISH )

Father’s name: ____________________ DOB: ___________

Cultured Amniocytes (1 T75 or 2 T25 flasks 70% confluent)

Please attach pedigree if relevant

DNA: 2ug total (at a minimum concentration of 70 ng/uL)

INDICATION FOR TESTING:

Other: ________________________________

Fetal Ultrasound Abnormality

(please specify below and attach copy of fetal ultrasound)

Parental Sample:

Brain malformation: ___________________________________

Maternal Blood: 5-10mL EDTA

Facial cleft: _________________________________________

Heart defect: ________________________________________

Paternal Blood: 5-10mL EDTA

Lung abnormality:_____________________________________

Diaphragmatic hernia: _________________________________

GI abnormality:_______________________________________

SPECIMEN COLLECTION:

GU abnormality:______________________________________

Skeletal abnormality: __________________________________

NT greater than or equal to 3.5mm: _______________________

Date: _____________________________

(DD/MM/YYYY)

Other: ______________________________________________

Time: _____________________________

Known familial microarray deletion/duplication syndrome

(provide copy of the result)

CVH Lab Use Only

Date Rec’d:(DD/MM/YYYY) _______________________ Time: _________________ # Tubes Rec’d: _________________

Comments: __________________________________________________________________________________________

Unit #

LAB #

PRENATAL MICROARRAY REQUISITION

Prenatal Microarray Requisition Form

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