Molecular Diagnostic Laboratory Requisition Form
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1
2Molecular Diagnostic
Accession #
LABORATORY MEDICINE AND PATHOLOGY
Laboratory
Client Response Centre
(780) 407-7484
CAPITAL HEALTH REGION LABORATORIES
Requisition
PHN / Healthcare Number
DynaLIFE DX
D
Patient Legal Name (Last)
(First)
(Initial)
DD
MM
YY
Copy to
M
O
Name ___________________________________
F
B
Physician Code ___________________________
Address
City
Prov.
Postal Code
Address _________________________________
________________________________________
Chart #
Patient Phone #
Lab #
Bill Type CPL
Alberta Health Care
PRIORITY
OR
Ordering Physician / Practitioner
Physician Code
Specimen Event Type
(specify tests)
CO
Company
OT
Out of Prov
IA
AUXILLARY
XX
Pre-paid
PB
Patient Bill
IP
IN PT
OP
OUT PT
Ordering Address / Location
Report Location Code
Co. name __________________________
AP
AMBUL
HC
HMCARE
Address ___________________________
ST
STAFF
Report address if different
__________________________________
EN
ENVIRON
Phone to
WCB
WORKER’S
____________
Client # ____________________________
COMP
Date specimen collected
Col. Location
DD
MM
YY
1.
INDICATION MUST BE PROVIDED BEFORE ANY GENETIC
TESTING CAN BE DONE.
2.
RESULTS WILL ONLY BE PROVIDED IF ALL THE
Collector
TIME (24 h)
RELEVANT SECTIONS OF THE REQUISITION ARE
COMPLETELY FILLED OUT.
SPECIMENS
PEDIGREE:
TEST REQUESTED
ALS
Amyotrophic Lateral Sclerosis
Blood
ATRX
Alpha Thal Mental Retardation
15 mL EDTA (mauve top)
A pedigree minimally indicating (with
ANGS
names) parents, sibs and children MUST
Angelman Syndrome
3 mL EDTA up to 1 year of age
accompany this requisition.
CF
Cystic Fibrosis
(then 3 mL / kg to a max. of 15 mL)
DVS
Del 22q11.21 - 23 (Di George and
CVS: 10 mg minimum - _______ mg
Velocardiofacial Syndromes)
Amniotic: Fluid 25 mL min. ____ mL
ED2
Hidrotic Ectodermal Dysplasia
Other (specify) __________________
FRAX
Fragile X
Date Specimen Drawn _______________
HC
Hemochromatosis
Recent Transfusion
HOKPP
Hypokalemic Periodic Paralysis
(date if known) _________________
HUNT
Huntington Disease
Ethnic background __________________
LCAD
Long Chain Acyl-CoA Dehydrog Def
Your reference No. _________________
MCAD
Med Chain Acyl-CoA Dehydrog Def
UAHMDL reference No. ______________
MTHFR
Methylene Tetrahydrofolate
Reductase Deficiency
Family Doctor ______________________
MYD
Myotonic Dystrophy
NHL
Non-syndromic Hearing Loss
INDICATION: (Check all relevant boxes)
OPMD
Oculopharangeal Muscular
Prenatal Testing (specify LMP)
Dystrophy
yy ______ / mm ______ / dd ______
PRSS
Hereditary Pancreatitis
Confirmation of clinical diagnosis
PWS
Prader-Willi Syndrome
Presymptomatic testing
SPMA
Spinal Muscular Atrophy
TORD
Torsion Dystonia-1
Carrier status
WMS
Williams Syndrome
Bank sample until further notice
UPD
Uniparental Disomy (parental
Other _________________________
samples required)
Clinical Features / Comments _________
(specify chromosome) ___________
I have reviewed the points on the back
_________________________________
of this form, as well as the benefits and
HCA
Hereditary Cancer: (ordering
_________________________________
limitations of genetic testing with the
restricted to Edmonton and
patient / guardian. I have answered all
Calgary genetics clinics)
____________________________________
the patient's / guardian's questions and
(specify) _____________________
have obtained verbal consent to order
MDG
Other (specify name and MIM#)
FAMILY HISTORY: (Required)
the above test(s).
____________________________________
Other family members tested previously?
Physician / Genetic Counsellor
Yes
No
print name _______________________
MDL USE ONLY
Patient No. ___________________________
INDEX Patient Name ______________
signature ________________________
Family No. ___________________________
SEE BACK OF FORM
Received ____________________________
CH-0854 Apr 2008
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