Drug Metabolism Test Name

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Drug Metabolism Test 431 Newton Road, 140 EMRB Iowa Institute of Human Genetics Iowa City, IA 52242-1078 Clinical Test Requisition Form Phone: 319-335-3688 | Fax: 319-335-3484 CLIA ID 16D2053873 | CAP# 8864771 www.medicine.uiowa.edu/humangenetics/

Patient Information Specimen Information Specimen Collection Date: ____ /____ / ______

MM / DD / YYYY Specimen Type: ☐ ~6mL EDTA whole blood - Place patient ID sticker here - ☐~3mL EDTA whole blood (pediatric) ☐10µg @ 110ng/ml (minimum) MRN: -OR- Accession #: Clinical Indication for Testing: Name: ______Last First

DOB: ____ /____ / ______Sex: ☐Male MM / DD / YYYY ☐Female

ICD-10 code: Ordering Options Select one or more options: ☐Infectious disease drugs: atazanavir, voriconazole ☐Anti-clotting drugs: clopidogrel ☐Neurologic/psychiatric drugs: amitriptyline, aripiprazole, ☐Cancer-related drugs: 6-mercaptopurine, capecitabine, fluorouracil, citalopram, clomipramine, desipramine, doxepin, escitalopram, nilotinib, ondansetron, rasburicase, tegafur, thioguanine, tropisetron fluvoxamine, imipramine, nortriptyline, paroxetine, pimozide, sertraline, ☐Immunosuppressants: azathioprine, tacrolimus tetrabenazine, trimipramine ☐Opioids: codeine, tramadol ☐All categories Reporting Information (fax# required to send results) Payment Information ***The IIHG will NOT submit to insurance. Institutional billing or Health Care Provider: payment by credit card is accepted. NPI: Billing Contact: Institution: Institution: Street Address: Street Address: City: State: Zip: City: State: Zip: Phone: Fax: Phone: Fax: Additional Report Recipient (fax# required to send results) Race and Ethnicity Health Care Provider: Select all that apply

Billing Contact: ☐American Indian or Alaska Native ☐Asian Institution: ☐Black or African American Street Address: ☐Native Hawaiian or Other Pacific Islander ☐White City: State: Zip: Hispanic or Latino? ☐Yes ☐No Phone: Fax: Shipping Instructions • Samples will be accepted Monday-Friday. Do not ship for Saturday delivery. • Samples should be stored and shipped at ambient temperature.

IIHG ID#______For office use only

Rev. Dec 2017 If you have questions please contact the IIHG at 319-335-3688 or [email protected] Page 1 of 2

Sample Requirements • Samples must be labeled with the patient's full name and date of birth. Samples received without both pieces of information cannot be processed and will be discarded. • Biological parent or other relative samples must be labeled with that person’s full name and date of birth, NOT the patient’s information. Samples received without both pieces of information cannot be processed and will be discarded. • 6 mL whole blood in lavender EDTA tube (3 mL pediatric minimum). OR 10µg DNA (A260/A280 1.8-2) resuspended in 0.1mM EDTA (10mM Tris HCl, 0.1mM EDTA, pH 8, Teknova Cat# T0220) Please note: If insufficient quality or quantity of DNA is obtained, an additional sample will be requested. Shipping Requirements • Samples should be stored and shipped at room temperature • Samples should be shipped for next day delivery, Monday-Friday. Samples are not received on weekends or US holidays • Please contact us at [email protected] or 319-335-3688 with any questions or concerns • Ship overnight to: Iowa Institute of Human Genetics University of Iowa 431 Newton Road, 140 EMRB Iowa City, IA 52242 Phone: 319-335-3688 Billing • Institutional billing, Visa and MasterCard are accepted • The IIHG will NOT bill insurance, Medicare or patients directly • Contact laboratory for CPT code information. CPT Codes • All drug categories: 81225, 81226, 81231, 81235, 81249, 81335, 81350 • Anti-clotting drugs: 81225 • Cancer-related drugs: 81226, 81235, 81249, 81335, 81350 • Immunosuppressants: 81231, 81335 • Opioids: 81226 • Infectious disease drugs: 81225, 81350 • Neurologic/psychiatric drugs: 81225, 81350

Rev. Dec 2017 If you have questions please contact the IIHG at 319-335-3688 or [email protected] Page 2 of 2