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. Cancer Probe by DNA FISH   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cancer Probe by DNA FISH
CPT Code: Interphase Analysis 88271 (each probe), 88275 MetaphaseAnalysis 88271 (each probe), 88274, 88291

Specimen Type: Blood, Bone Marrow, Lymph Node, Tumor

Tube Type/Collection Container: Green top (sodium heparin) tube or special THC tube

Collection Volume: 1.0 mL (minimum 0.5 mL) or 1.0 mm3

Cause for rejection: Clotted, non-sterile, or frozen specimen

Storage: Ambient

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

Methodology: Cells are fixed to slides, hybridized overnight with appropriate DNA probe(s), washed, and counterstained. 10 metaphase cells or 100-300 interphase nuclei are analyzed using fluorescence microscopy and images are digitally captured using analysis software.

Special Instructions: Include all pertinent medical findings on the requisition with suspected diagnosis and/or indication(s) for the testing.

TAT: 1-7 days


Lab/Phone: 330-543-8483

Additional Info: Interpretation is provided with report

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: