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Engraftment (Chimerism) Donor

Molecular Diagnostics : DNA

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. Engraftment (Chimerism) Donor
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

EDDNZ/DNA1

Specimen Type:

Whole Blood, Bone Marrow, Cord blood

Tube Type:

Purple top (EDTA) tube

Collection Volume:

3.0 mL(minimum 1.0 mL) whole blood or 3.0 mL (minimum 0.2 mL) bone marrow or cord blood

Cause for Rejection:

QNS or unacceptable specimen type

Storage:

Ambient

Availability:

Mon-Fri

Methodology:

Polymerase Chain Reaction (PCR) amplification of short tandem repeats/capillary electrophoresis

Lab/Phone:

330-543-8722

TAT:

7-14 days

CPT Code:

81265

Synonyms:

Chimerism

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