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 DNA Analysis   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fragile X DNA Analysis
CPT Code: 81243,81244

Specimen Type: Blood

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

Collection Volume: 6.0 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), Southern Blot Probe Hydridization

Special Instructions: Pertinent medical findings, family history, and suspected diagnosis must accompany request. Genetic counseling is available. Family studies may be necessary to establish or confirm carrier status.

TAT: 2 wks - males, 1 month - females


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 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: