Cytogenomic Microarray Analysis of Postnatal Blood

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:

Hospital:

Test ID :

LAB4180

Specimen Type:

3 mL whole blood collected in one EDTA (purple top) tube. Specimen minimum volume is 1 mL.

Cause for Rejection:

Nonsterile, gross contamination, clotted or frozen specimen, wrong anticoagulant.

Storage:

Transport blood at room temperature. Upon arrival in laboratory, store refrigerated.

Availability:

Mon-Fri (0700-1600) Sun (0900-1300)

Methodology:

Chromosomal Microarray (CMA) Using Affymetrix Cytoscan DX

Lab/Phone:

330-543-8483

TAT:

28 Days

CPT Code:

81229