Microarray Test Requisition Form
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1
2Patient Acct No.
Patient Name (Surname First)
MICROARRAY TEST REQUISITION
Patient Unit No.
D.O.B.
Sex
GENETICS LABORATORY - Credit Valley Hospital
2200 Eglinton Ave. W., Rm 2H144
Tel: (905) 813-1100 x6288
Address/City/Province/Postal Code
Mississauga, ON L5M 2N1 Canada
Fax: (905) 813-3854
Health Card Number
Version
Note: Complete both pages of this requisition in full to avoid delay in reporting result.
PHYSICIAN INFORMATION
Referring Physician: ________________________________
Copy To: _________________________________________
Registration #: ____________________________________
Registration #: ____________________________________
Address: _________________________________________
Address: _________________________________________
Phone: ___________________ Fax: __________________
Phone: ___________________ Fax: __________________
Signature (required): ________________________________
SPECIMEN COLLECTION:
DATE: ______________________________________ TIME: ____________________
DD/MM/YYYY
HH:MM
Specimen Type
Peripheral Blood in EDTA: 3mL minimum (1mL minimum for newborns)
Fibroblast Cell Culture: 2x T25 confluent flasks at room temperature
Extracted DNA: 2ug total (at a minimum concentration of 70 ng/uL)
Karyotype
(if known)
Developmental Delay or Intellectual Disability
Developmental Delay or Intellectual Disability and additional clinical features.
Indications for Testing
Complete Clinical Description Form (page 2)
Two or more congenital anomalies.
Complete Clinical Description Form (page 2)
Relevant Family History:
Pedigree (at least 3-generation, when available and if applicable):
CVH Lab Use Only
Date Recieved:(DD/MM/YYYY) _______________________________________________ Time: _______________________
# Tubes Recieved: ___________________
Comments: ______________________________________________________
Unit #:
LAB #:
MICROARRAY TEST REQUISITION
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