Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Chromosome Analysis, Amniotic Fluid   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chromosome Analysis, Amniotic Fluid
CPT Code: 88235, 88269, 88280, 88285, 88291

Specimen Type: Amniotic fluid

Tube Type/Collection Container: Sterile tissue culture flask provided by laboratory

Collection Volume: 25.0-40.0 mL (minimum 10.0 mL)

Cause for rejection: Clotted, non-sterile, or frozen specimen; specimen found not to be amniotic fluid

Storage: Ambient

Availability: Mon-Fri (0700-1600) Sat (0900-1300)

Methodology: Amniocyte cell culture, harvest and chromosome analysis with G-banding

Special Instructions: Discard the first 2.0 mL of fluid in order to minimize maternal cell contamination. DNA FISH analysis requires an additional 5.0 mL of amniotic fluid. Include pertinent medical findings on the requisition with suspected diagnosis and/or indication(s) for testing.

TAT: 7-14 days


Lab/Phone: 330-543-8483

Additional Info: Interpretation is provided with report. Follow-up studies recommended as appropriate.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: