Chromosomal Microarray (Array Cgh) Requisition Form
ADVERTISEMENT
1
2Patient label placed here (if applicable) or if labels are
not used, minimum information below is required
Name
(last, fi rst)
Birthdate
Gender
(yyyy-Mon-dd)
Chromosomal Microarray (CMA) Requisition
PHN #
Cytogenetics Laboratory North: University of Alberta Hospital
Address
Cytogenetics Laboratory South: Alberta Children’s Hospital
For other cytogenetics or molecular diagnostic genetic testing, please complete the appropriate requisition
form
Referring Physician
Copy to
Name
Name
Address
Address
Phone
Phone
Fax
Fax
Specimen Type
Blood
Prenatal Samples
CVS: 10 mg minimum
EDTA (lavender): 3-5 mL (1-3 mL for newborns)
Amniotic: Fluid 25 mL minimum
AND
DNA
NaHep (green): 3-5 mL (1-3 mL for newborns)
Extracted from
____________________
(tissue type)
Tissue
DNA quantity:
______________________________
Specify tissue type
_________________________
DNA concentration:
__________________________
Banked in:
Edmonton
Calgary
Karyotype and previous cytogenetics lab #/ID
(required if known)
______________________________________________
Primary Indication: Clinical details must be provided on back to ensure timely and accurate reporting
Prenatal
Ultrasound anomaly(ies)
Nuchal translucency greater than or equal to 3.5 mm
Is this an on-going pregnancy?
Yes
No
Date of last mentrual period
(yyyy-Mon-dd)
____________
Specify gestational age at time of procedure:
Weeks
________
Days
________
Postnatal
Isolated autism
Isolated developmental delay
Developmental delay and additional clinical features
Congenital anomaly(ies)
Parental Follow-up
Name of Proband
___________________________
Proband lab number
__________________________
Mother’s name
____________________________
Father’s name
____________________________
Family History: Please provide relevant family history
Pre-test counselling has been provided
Provider Name
Signature
Date
(yyyy-Mon-dd)
For Laboratory Use Only
Initials
Specimen type/comments
Lab number
Date received
(yyyy-Mon-dd)
Collected by
Data collected
(print name)
(yyyy-Mon-dd)
Specimen Drawn
Date
Time
(yyyy-Mon-dd)
(hh:mm)
Collector Name
ID #
09591(Rev2015-11)
Page 1 Side A
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business