DNA Extraction & Hold

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. DNA Extraction & Hold
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

DNEXZ DNA Extraction

Specimen Type:

Blood

Tube Type:

Purple top (EDTA)

Collection Volume:

4 mL (minimum 3 mL)

Storage:

Refrigerated

Availability:

Mon-Fri

Methodology:

DNA Extraction

Lab/Phone:

330-543-8483

CPT Code:

81479

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