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. Sub-Telomere Analysis by DNA FISH   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Sub-Telomere Analysis by DNA FISH
CPT Code: 88271x15, 88274, 88291

Specimen Type: Blood, Bone Marrow, Lymph Node, Tumor, Amniotic Fluid

Tube Type/Collection Container: Blood, Bone Marrow: Green top (sodium heparin) tube, Lymph Node, Tumor: Sterile tissue culture flask provided by laboratory or sterile container with sterile saline or tissue culture medium

Collection Volume: Aminotic fluid: 20.0 mL (minimum 5.0 mL); Blood: 5.0 mL (minimum 1.0 mL); Bone Marrow: 1.0 mL (minimum 0.5 mL); Tissue: 1.0 mm3

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

Storage: Ambient

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

Methodology: Following standard chromosome preparation, cells are fixed to slides, hybridized overnight to appropriate DNA probe(s), washed, and counter-stained. 2-5 metaphases are evaluated for each sub-telomeric probe using a fluorescence microscope and images are captured digitally using image analysis software.

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

TAT: 24 hours-2 weeks


Lab/Phone: 330-543-8483

Additional Info: Interpretation is provided with 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: