DNA Extraction & Hold
| 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 :
LAB4179
Specimen Type:
3 mL whole blood or bone marrow collected in one EDTA (purple top) tube.
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:
Manual DNA Extraction
Lab/Phone:
330-543-8483
TAT:
14 Days
CPT Code:
81479
