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. UBE3A Gene Sequence Analysis   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for UBE3A Gene Sequence Analysis
CPT Code: 81406

Specimen Type: Whole Blood

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

Collection Volume: 3.0 mL Whole Blood

Storage: Ambient

Availability: Sent to Reference Laboratory

Methodology: Polymerase Chain Reaction (PCR) followed by DNA Sequence Analysis

Special Instructions: Send specimen in original tube Requires "Informed Consent for Genetic Testing"

TAT: 14-20 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: