Form Ch-0327 - Genetics Laboratories Requisition Form printable pdf download

Genetics

Accession #

LABORATORY MEDICINE AND PATHOLOGY

Laboratories

Client Response Centre

(780) 407-7484

AHS EDMONTON ZONE LABORATORIES

Requisition

PHN / Healthcare Number

DYNACARE KASPER MEDICAL LABORATORIES

Patient Legal Name (Last)

(First)

(Initial)

 Copy to

 M

Name ___________________________________

 F

Physician Code ___________________________

Address

City

Prov.

Postal Code

Address _________________________________

_________________________________________

Chart #

Patient Phone #

Lab #

Bill Type CPL  Alberta Health Care

 PRIORITY

Ordering Physician / Practitioner

Physician Code

Specimen Event Type

(specify tests)

CO  Company

OT  Out of Prov

 AUXILLARY

XX  Pre-paid

PB  Patient Bill

 IN PT

 OUT PT

Ordering Address / Location

Report Location Code

Co. name __________________________

 AMBUL

 HMCARE

Address ___________________________

 STAFF

Report address if different

___________________________________

 ENVIRON

Phone to

WCB

 WORKER’S

____________

Client # ____________________________

COMP

Date specimen collected

Col. Location

INDICATION MUST BE PROVIDED BEFORE ANY GENETIC

TESTING CAN BE DONE.

RESULTS WILL ONLY BE PROVIDED IF ALL THE

Collector

TIME (24 h)

RELEVANT SECTIONS OF THE REQUISITION ARE

COMPLETELY FILLED OUT.

CYTOGENETICS

MOLECULAR GENETICS

INDICATIONS ______________________________

Check all relevant boxes

___________________________________________

 Prenatal Testing (specify LMP)

___________________________________________

yy ________ / mm ________ / dd ________

___________________________________________

 Confirmation of clinical diagnosis

PERIPHERAL BLOOD SPECIMEN

SPECIMENS

 Presymptomatic testing

B(AP)  Karyotype, blood

 Blood: ____ 15 mL EDTA (mauve top)

 Carrier status

Specimen: Minimum 2 mL (1 mL for infants)

30 mL for Hereditary Cancer Specimens

 Determine feasibility of prenatal diagnosis

Sodium heparin (green top)

____ 3 mL EDTA up to 1 year of age ONLY

 Required for family study (No report)

FIBROBLAST CULTURE

(then 3 mL / kg to a max. of 15 mL)

 Bank sample until further notice

All Specimens in sterile Hanks BSS

 CVS: 10 mg minimum - __________________ mg

 Documented family history of indicated disease

CTIS(AP)  Skin Biopsy

 Amniotic Fluid: 25 mL minimum - __________ mL

 Possible family history of indicated disease

 Other (specify) __________________

 Specimen storage only

 Other (specify) ____________________________

 Other ___________________________________

 For DNA

DATE SPECIMEN DRAWN ____________________

II. Test Required

PRENATAL

 RECENT TRANSFUSION

ANGS

 Angelman Syndrome

AMNI(AP)  Karyotype, amniotic fluid

(date if known) _____________________________

 Cystic Fibrosis

CVS(AP)

 Karyotype, chorionic villus sampling

Ethnic background ___________________________

DVS

 Del 22q11.21 - 23

Onset of LMP _______________________________

Your reference No. ___________________________

(Di George & Velocardiofacial Syndromes)

Estimated Gestational age _____________________

UAHMDL reference No. _______________________

FRAX

 Fragile X

Last name of spouse _________________________

Family Doctor _______________________________

 Hemochromatosis

First / middle ________________________________

IMPORTANT:

MTHFR  Methylene Tetrahydrofolate Reductase

Spouse DOB ________________________________

Other family members tested previously?

HUNT

 Huntington Disease

Dr. performing procedure ______________________

 Yes

 No

MYD

 Myotonic Dystrophy

# of inserts _________________________________

INDEX Patient Name _________________________

NHL

 Non-syndromic Hearing Loss

Multi-pregnancy

 Yes

 No

 Uncertain

PEDIGREE:

PCKD

 Polycystic Kidney Disease

Complications & unusual meds during this pregnancy

PWS

 Prader-Willi Syndrome

___________________________________________

SPMA

 Spinal Muscular Atrophy

___________________________________________

TORD

 Torsion Dystonia-1

___________________________________________

WMS

 William Syndrome

___________________________________________

HCA

 Hereditary Cancer: (ordering restricted

Number of Pregnancies

to Edmonton and Calgary genetics clinics)

______ living

_____ deceased

(specify) ___________________________

______ tubal preg

_____ spontaneous abortions

MDG

 Other (specify name and MIM#)

______ stillbirths

_____ therapeutic abortions

___________________________________________

Familial and / or genetic disorder(s) in patient’s or

___________________________________________

spouse’s family

FOR ALL MOLECULAR GENETIC TESTING:

___________________________________________

A pedigree minimally indicating (with names) parents,

___________________________________________

sibs and children MUST accompany this requisition.

MDL USE ONLY

___________________________________________

This individual / family is aware of, and consents to,

Patient No. _________________________________

___________________________________________

the tests requested. Wherever pre-test genetic

counselling would be warranted, it has been provided

Family No. __________________________________

___________________________________________

to my satisfaction.

Received ___________________________________

Geneticist / Physician _________________________

CH-0327 Sep 2001

Form Ch-0327 - Genetics Laboratories Requisition Form

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