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, Bone Marrow, Newborn   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chromosome Analysis, Bone Marrow, Newborn
CPT Code: 88237, 88262, 88291

Specimen Type: Bone Marrow

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

Collection Volume: 1.0 mL (minimum 0.5 mL)

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

Storage: Ambient

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

Methodology: Chromosome harvest of mitotic cells (with and without culturing) with G-banding

Special Instructions: Rapid (24 hour) determination of chromosome copy number and category for sex chromosomes or to r/o trisomy 13, 18 or 21 can be ordered with peripheral blood sample (see Sex Chromosome Analysis by DNA FISH, Newborn Smear or Trisomy Analysis (Chromosome 13, 18, or 21) by DNA FISH, Newborn Smear). Include pertinent medical findings on the requisition with suspected diagnosis and for indication (s) for the testing.

TAT: 2 hours-7 days (some ASAP results may be available within 4 hours)


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: