FISH, Tissue
| 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. FISH, Tissue | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Available FISH Probes:
EWSR1 (22q12)
N-MYC (2p24.1)
ALK (2p.23)
88271 (DNA probe, each)
88275 (Interphase in situ hybridization, 100 to 300 cells, each)
88291 (Interpretation and Report)

