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. Fragile X (FMR1) DNA Analysis with Reflex to Methylation Analysis   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fragile X (FMR1) DNA Analysis with Reflex to Methylation Analysis
CPT Code: 81243, (81244 if reflexed)

Specimen Type: Whole Blood

Tube Type/Collection Container: Purple top (EDTA) tube

Collection Volume: 3.0 mL (minimum 1.0 mL)

Cause for rejection: Specimen clotted, stored at room temperature, > 5 days old; improper anticoagulant.

Storage: Refrigerated

Availability: Mon-Fri

Methodology: Polymerase Chain Reaction (PCR), Capillary Electrophoresis

Special Instructions: Please indicate reason for testing (e.g. family history, suspected diagnosis, carrier testing). Samples with full mutation and premutations will be reflexed to Methylation Analysis at an additional charge.

TAT: 10-14 days


Lab/Phone: 330-543-8722

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

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


Physician Signature: Date: