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. Chromosomal Microarray   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chromosomal Microarray
CPT Code: 81228

Specimen Type: Blood

Tube Type/Collection Container: Purple (EDTA) tube AND Green (Sodium heparin) tubes; Whole Blood

Collection Volume: 5.0 mL (minimum 2.0 mL) EDTA Whole Blood AND 5.0 ml (minimum 2.0 mL) NA Heparin Whole Blood

Storage: Purple (EDTA) refrigerated; Green (Sodium Heparin) ambient

Availability: Sent to Reference Laboratory

Methodology: Microarray comparative genomic hybridization

Special Instructions: Must collect both purple (EDTA) and green (sodium heparin) tubes; Patient must be pre-authorized for testing Requires "Informed Consent for Genetic Testing"

TAT: 8-21 days


Lab/Phone: 330-543-8418

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: