Alberta Children’s Hospital 2888 Shaganappi Trail NW, Calgary, AB BONE MARROW PATHOLOGY REQUISITION Hematology (Ped. Collections): 403-955-7382 Diagnostic and Scientific Centre (DSC) 3535 Research Road NW, Calgary, AB Molecular Hematology: 403-770-3699 Cancer Cytogenetics: 403-770-3690 Foothills Medical Centre 1403 - 29 Street NW, Calgary, AB Special Hematology: 403-944-8070 Flow Cytometry: 403-944-4765 ORDERING PHYSICIAN

Last Name:______

Full First Name:______

Location (Unit/Clinic):______If Flow Cytometry FAX result to: (Name) ______Affix addressograph imprint or patient label to ALL PAGES, or clearly print patient’s full name (last (Number ) ______name, first name), date of birth, gender, Personal Health Number and Medical Record Number COPY TO: COLLECTED BY: DATE COLLECTED: TIME COLLECTED:

1) ______Last Name Full First Name Office Address (Location) COLLECTED AT: PATIENT LOCATION: ACH FMC PLC RGH SHC 2) ______Last Name Full First Name Office Address (Location) OTHER: SPECIMEN TYPE: SITE: PREVIOUS SPECIMENS?

Aspirate Biopsy Lt. Iliac Crest Rt. Iliac Crest Sternum Bone Marrow Other, specify: ______No

CLINICAL DIAGNOSIS AND HISTORY: Clinical Diagnosis (check off appropriate boxes): Chemotherapy/Other Therapy: Additional Clinical Information/Special Request INITIAL STAGING FOLLOW-UP

Anemia Pancytopenia Thrombocytopenia Date of Last Therapy: Leukemia, specify ______Presence of Serum/Urine Monoclonal Peak: Lymphoma, specify ______IgG IgM IgA Kappa Plasma Cell Neoplasm, specify ______Myeloproliferative Neoplasm, specify ______Lambda Other______Procedure Notes: Myelodysplasia Transplanted: Yes No Clotted Dry Tap Difficult draw Other, specify ______Gender of Donor: Male Female Other______

HEMATOLOGY/MORPHOLOGY:

BM Bone Marrow Pathology Molecular Hematology DNA Specimen (Initial Bone Marrow)

ADDITIONAL STUDIES: (FOR LAB USE ONLY) MOLECULAR HEMATOLOGY CANCER CYTOGENETICS FLOW CYTOMETRY – BONE MARROW For sorted Chimerism Studies, see Flow Sort (CG CYTOGEN)

PAN/MDS - Pancytopenia/Myelodysplasia Panel Chimerism Studies – Unsorted Chromosomes DNAR BM Recipient Cells LEUK - Leukemia Panel Philadelphia Chromosome Transcript FISH PHLR BM Analysis (Nested PCR) LOMA - Lymphoma Panel NGS APL Transcript Analysis APL BM MM - Plasma Cell Neoplasm Panel (Nested PCR) Hold JAK2 BM JAK2-V617F Mutation Analysis MPD - Myeloproliferative Neoplasms For Cancer Cytogenetics use only: FLT3 BM FLT-3 Mutation Analysis FLOW SORT Quantitative PCR Analysis of BCR-ABL1 Volume (ml): Immunophenotyping QPCRPH1 Fusion Gene Transcripts Chimerism Studies – sorted Count: NPM1 BM NPM1 Mutation Analysis T cell B cell Culture set up: MH Misc other ______Myeloid Other:______File Number:

DATE RECEIVED: PBS # GENERAL LAB ACC LABEL AP ACC LABEL

TIME RECEIVED:

TAT:

Laboratory Information Centre: 403-770-3600 REQ9061BM Rev 2.01