We are experiencing exceptionally high volumes in our emergency rooms.
Every patient is important to us, and we are doing all we can to provide care quickly and efficiently.

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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