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, Tumor   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chromosome Analysis, Tumor
CPT Code: 88239, 88262, 88280, 88291

Specimen Type: Tumor biopsy

Tube Type/Collection Container: Sterile container with tissue culture medium (can be provided by laboratory)

Collection Volume: Biopsy of viable tissue (minimum 1 mm3)

Cause for rejection: Gross contamination, frozen specimen, formalin fixed tissue Note: chromosomes 13, 18, 21, X and Y can be counted by interphase FISH to reveal aneuploidy and polyploidy.

Storage: Ambient

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

Methodology: Collagenase dissociation of cells, short term cell culture, subsequent harvesting, and chromosome analysis with G-banding

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

TAT: 2-4 weeks


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: