AMN FISHCytogenetics Requisition - PRENATALv3

St. Augustine's University **We aren't endorsed by this school
Nov 19, 2023
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CYTOGENETICS REQUISITION - PRENATAL CYTOGENETICS LABORATORY Division of Diagnostics Medical Genetics Pathology and Laboratory Medicine, Room , 600 University Ave, Toronto, Ontario, Canada, M5G 1X5 PATIENT INFORMATION (PLACE LABEL HERE or TYPE) Last Name: First Name: MRN: Visit #: Date of Birth: Address: Gender: Male Female Unknown Health Card # & Version Code: Province MSH Clinic (if applicable): - REPORTING INFORMATION Physician/Midwife ______________________________________ Institution __________________________________________ Address __________________________________________ __________________________________________ Phone ________________ Fax _________________ E-mail __________________________________________ Additional Report Recipient ______________________________ Institution __________________________________________ Address __________________________________________ __________________________________________ Phone ________________ Fax _________________ E-mail __________________________________________ PATIENT FAMILY HISTORY Clinical information / pedigree: Has this patient had previous cytogenetics testing? No Yes Have other relatives had cytogenetics testing? No Yes Relationship to Patient: __________________________________ DOB: _____________________ MRN: _______________________ If cytogenetics testing was previously done, please attach a copy of original report SAMPLE INFORMATION & TEST REQUIRED CLINICAL INDICATION SPECIMEN INFORMATION Date sample collected ______________________ Gestation: ________________ Specimen Type Submitted Amniotic Fluid Fetal Urine Ascites Fluid Pleural Effusion Cystic Hygroma Fluid Chorionic Villi (CVS) Fetal Blood (Cordocentesis) [ Blood in EDTA (lavender top) ] Maternal Blood for MCC [ Blood in EDTA (lavender top) ] TEST REQUIRED Aneuploid Screen Microarray DNA banking Send-out Test Indicate Specimen Requirements attach appropriate paperwork, instructions, waybill and pre-paid account # Amniotic Fluid - Volume ________________________________________ Chorionic Villi - Volume ________________________________________ Cultured Cells - # T25 flasks _____________________________________ DNA retrieve for send-out Volume _____________________________ REASON FOR REFERRAL Alloimmunization Carrier of Genetic Condition Fetal Ultrasound Findings (specify below) Late Maternal Age Multiple Pregnancy (specify Fetus ID below) Previous Child/Pregnancy Abnormality (specify below) Prenatal Screening (specify result details below; include report if applicable ) TTTS (Twin to Twin Transfusion Syndrome) DETAILS: SPECIMEN REQUIREMENTS Prenatal specimens for Aneuploid screen & Microarray: Amniotic fluid: 20 to 30cc CVS * : 10 to 15mg * 3 to 5mL of maternal blood in EDTA minimum vol 3 ml (lavender tube) must accompany all CVS Specimens [for Maternal Cell Contamination (MCC) Testing] INSTRUCTIONS FOR SUBMISSION OF SPECIMENS Deliver specimens by 4:00pm to: Pathology & Laboratory Medicine Rapid Response Laboratory ATTENTION CYTOGENETICS LABORATORY 600 University Avenue | th Floor, Room | Toronto, Ontario, Canada M5G 1X5
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