Molecular Genetics Laboratory Oncology Studies Requisition Form
ADVERTISEMENT
1I
n
t
e
r
n
a
l
L
a
b
u
s
e
o
n
l
y
I
n
t
e
r
n
a
l
L
a
b
u
s
e
o
n
l
y
I
n
t
e
r
n
a
l
L
a
b
u
s
e
o
n
l
y
CR# or Hospital ID #: ____________________
Patient Name: __________________________________________________
(Last)
(First)
Molecular Genetics Laboratory
Date of Birth (YYYY/MM/DD): ______/_____/_____
Sex: M/F
Oncology Studies Requisition
76 Stuart Street, Douglas 4, Room 8-415
Health Card #: ____________________________ Expiry Date: _________
Kingston, ON K7L 2V7
Tel: 613)549-6666 ext. 4892
Address: ______________________________________________________
FAX: 613-548-1356
Postal Code: ________________
Phone: ________________________
In-house delivery tube station: #31
Specimen Requirements
Collection Centre: ___________________________
Collected by: ___________________________(please print)
□
Date
: ________/____/____
Time: ___________
Collected at Room Temperature and within 24 hours
(YYYY/MM/DD)
Note: The requisition and specimen must carry the same two unique patient identifiers or the sample may be rejected.
□
□
Blood (10 cc - EDTA vacutainer - lavender or pink)
Lymph Node
□
□
Bone Marrow (EDTA rinsed syringe)
Other Tissue (specify): __________________________
Principal Diagnosis and Therapy
Test Requested
□
Hematopathologist to Triage (DNA will be held until hematopath review completed)
□
Immunoglobulin/T cell receptor gene rearrangements
□
JAK2
□
Qualitative BCR/ABL(for diagnosis only) please specify below: - samples must be received within 24 hours of collection
□
□
□
CML breakpoints
ALL breakpoints
CML & ALL breakpoints
□
Quantitative BCR/ABL (for disease monitoring) – samples must be drawn in the morning and received in the lab before
noon. DO NOT collect samples on Fridays. This sample will be referred out for testing.
□
Other: _____________________________________________________
Report to: (Physician Information)
Name: _______________________________________________ Phone (___)___________ FAX: (___)___________
Address: __________________________________________________
City: _________________________________
Postal Code: ____________
CPSO#: _____________________
OHIP Billing #: ___________________
Signature: _____________________________________________________
Internal Lab Use Only:
P
l
a
c
e
L
a
b
e
l
H
e
r
e
P
l
a
c
e
L
a
b
e
l
H
e
r
e
Z:\genetics-g\requisitions\DNA REQS\KGH Molecular Genetics Oncology requisition.doc
Revised: 2015/05/12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business