Cytogenetics Laboratory Requisition Form

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CR# or Hospital ID #: ______________________
Patient Name: __________________________________________________
(Last)
(First)
Cytogenetics Laboratory
Date of Birth (YYYY/MM/DD): ______/_____/_____
Sex: M/F
Requisition Form
76 Stuart Street, Douglas 4, Room 8-423
Health Card #: ____________________________ Expiry Date: _________
Kingston, ON K7L 2V7
Tel: 613)549-6666 ext. 4219
Address: ______________________________________________________
FAX: 613-548-1356
Postal Code: ________________
Phone: ________________________
In-house delivery tube station: #31
Collection Centre: ___________________________
Collected by: ___________________________(please print)
Date
: ________/____/____
Time: ___________
Collected at Room Temperature
(YYYY/MM/DD)
Note: The requisition and specimen must carry the same two unique patient identifiers or the sample may be rejected
SPECIMEN TYPE - Keep all specimens at room temperature.
Blood (5 cc - Sodium Heparin)
CVS – to be sent to Mount Sinai Hospital
Bone marrow (collected in Sodium Heparin)
Solid tissue (specify) ______________________________
Amniotic fluid - please specify below:
Solid tumour:
Paraffin Embedded
Clear
Cloudy
Bloody
Dark
Other: _____________________________
TEST REQUESTED
Routine chromosome analysis
FISH (specify probe): _____________________________
QF-PCR
Other (specify) __________________________________
ROUTINE
STAT
GESTATION __________________________ weeks
REASON FOR TESTING: (Specimens will not be analyzed unless adequate information is provided)
CONSTITUTIONAL:
PRENATAL:
ONCOLOGY:
Developmental delay
AMA
New diagnosis___________
Short stature
Abnormal US (specify)____________
_______________________
Infertility
Screen positive(specify)___________
Follow-up _______________
Multiple miscarriages
Family history(specify)_____________
_______________________
Other (specify) ________________
Other(specify)___________________
Other (specify) ___________
____________________________
______________________________
_______________________
Additional Information: _____________________________________________________________________________
________________________________________________________________________________________________
Report to: (Physician Information)
Name: _______________________________________________ Phone (___)___________ FAX: (___)___________
Address: _____________________________________________
City: ________________
Postal Code: _________
CPSO#: ____________
OHIP Billing #: ___________ Signature: __________________________________________
Internal Lab Use Only:
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Z:\genetics-g\requisitions\CYTOGENETICS REQS\KGH Cytogenetics requisition.doc
Revised: 2015/05/12

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