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. Aneuploidy Analysis, Chromosomes 13, 18, 21, X and Y by DNA FISH   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Aneuploidy Analysis, Chromosomes 13, 18, 21, X and Y by DNA FISH
CPT Code: 88271x5, 88275, 88291

Specimen Type: Amniotic fluid

Tube Type/Collection Container: Sterile tissue culture flask provided by laboratory

Collection Volume: 5.0 mL (minimum 3.0 mL)

Cause for rejection: Clotted, non-sterile, or frozen specimen; specimen found not to be amniotic fluid

Storage: Ambient

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

Methodology: Uncultured amniocytes are fixed to slides, hybridized overnight to appropriate DNA probe(s), washed, and counterstained. 100-300 cells are analyzed using a fluorescence microscope. Images are captured digitally using image analysis software.

Special Instructions: Discard the first 2.0 mL of fluid in order to lessen the possibility of maternal cell contamination. The presence of maternal cells in the fluid may compromise the results. Typically in situ hybridization studies are confirmed by standard cytogenetic studies. Amniotic fluid karyotype requires an additional 10.0 mL of amniotic fluid. Include pertinent medical findings on the requisition with suspected diagnosis and/or indication(s) for testing.

TAT: 24 hours-5 days


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: