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Cytogenomic Microarray Analysis of Postnatal Blood

Cytogenetics Laboratory : Cytogenetics

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. Cytogenomic Microarray Analysis of Postnatal Blood
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

MCRY1 / CYTO

Specimen Type:

Blood

Tube Type:

Purple (EDTA) tube AND Green top (Sodium heparin) tube; Whole blood

Collection Volume:

3.0 mL (minimum 2.0 mL) purple top (EDTA) and 2.0 mL (minimum 1.0 mL) Green top (Sodium heparin) tubes

Storage:

Ambient

Methodology:

Chromosomal Microarray (CMA) Using Affymetrix Cytoscan DX

Special Instructions:

Must collect both Purple (EDTA) and Green (sodium heparin) tubes

Lab/Phone:

330-543-8483

TAT:

~4 weeks

CPT Code:

81229

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Cytogenomic Microarray Analysis of Postnatal Blood

Cytogenetics Laboratory : Cytogenetics

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