Kgh Molecular Genetics Laboratory Requisition Form
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CR# or Hospital ID #: ______________________
Patient Name: __________________________________________________
(Last)
(First)
Molecular Genetics Laboratory
Date of Birth (YYYY/MM/DD): ______/_____/_____
Sex: M/F
Requisition Form
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
(YYYY/MM/DD)
Note: The requisition and specimen must carry the same two unique patient identifiers or the sample may be rejected
Blood
Prenatal Specimen (
notify lab )
□
□
□
DNA
5-15 µg
EDTA (lavender or pink) 10 cc
Cultured Amniocytes - 2 x T25 Flasks
□
□
Other (specify):____________
Cultured CVS - 2 x T25 Flasks
Molecular Genetics Tests
□
□
□
Amyloidosis
Hemophilia A
Long QT
□
□
□
Factor V Leiden & Prothrombin
Hemophilia B
Other
(call lab to confirm if testing is peformed here):
□
□
Fragile X Syndrome
MTHFR
________________________________
□
□
Hemochromatosis
Huntington’s Disease
Information Requested/Reason for Referral
□
□
Diagnostic Testing
Ship specimen directly to outside laboratory
□
□
Predictive testing
Bank DNA until further notice
(referral to genetics clinic is recommended)
□
□
Carrier status
Other: _______________________________
(family history of this disorder)
Patient/Family information
Pregnancy Information
Ethnic background __________________________________
If this individual or the partner of this
□ This individual is the index (first identified) case OR
individual is currently pregnant:
□ Index Case in Family:
L.M.P. (YYYY/MM/DD): _______/_____/_____
Name _________________________ DOB: ____/___/___
Amnio (YYYY/MM/DD): _______/_____/_____
CVS (YYYY/MM/DD): _______/_____/_____
Relationship to this patient __________________________
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
equisitionsDNA REQSKGH Molecular Genetics requisition.doc
Revised: 2015/05/12
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