Stickler Syndrome Type I & II

Centralized Core Laboratory : Chemistry

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. Stickler Syndrome Type I & II
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

STL12 CTGT

Specimen Type:

Whole Blood

Tube Type:

Purple top (EDTA) tube

Collection Volume:

5.0 mL (minimum 4.0 mL)

Storage:

Ambient

Availability:

Sent to Reference Laboratory

Methodology:

DNA Sequencing

Special Instructions:

Requires Informed Consent for Genetic Testing.

Lab/Phone:

330-543-8418

TAT:

3-4 weeks

Additional Info:

Whole blood should be refrigerated until shipped. All samples can be shipped at ambient temperature via an overnight courier.

CPT Code:

81479 X2

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