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Anemia Thrombophilia Hematology

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Anemia Thrombophilia Hematology Submit this form along with the appropriate UNIVERSITY OF MINNESOTA PHYSICIANS OUTREACH LABS Molecular requisition (Molecular Diagnostics or MOLECULAR DIAGNOSTICS (612) 273-8445 Molecular NGS Oncology). DATE: TIME COLLECTED: PCU/CLINIC: AM PM PATIENT IDENTIFICATION DIAGNOSIS (Dx) / DIAGNOSIS CODES (ICD-9) - OUTPATIENTS ONLY SPECIMEN TYPE: o Blood (1) (2) (3) (4) PLEASE COLLECT 5-10CC IN ACD-A OR EDTA TUBE ORDERING PHYSICIAN NAME AND PHONE NUMBER: Tests can be ordered as a full panel, or by individual gene(s). Please contact the genetic counselor with any questions at 612-624-8948 or by pager at 612-899-3291. _______________________________________________ Test Ordered- EPIC: Next generation sequencing(Next Gen) Sunquest: NGS Ghosal hematodiaphyseal syndrome Anemia Thrombophilia TBXAS1 Griscelli syndrome Anemia, hypochromic microcytic Antithrombin deficiency Full Panel Full Panel SERPINC1 MYO5A SLC11A2 Coumadin resistance RAB27A STEAP3 VKORC1 MLPH Congenital dyserythropoietic Heparin cofactor II Hemochromatosis anemias SERPIND1 Full Panel Full Panel Kininogen deficiency HFE CDAN1 KNG1 HAMP SEC23B Plasminogen TFR2 KLF1 PLG SLC40A1 LPIN2 Prekallikrein FTH1 GATA1 KLKB1 HFE2 Hemolytic anemia Protein C deficiency Hereditary spherocytosis Full Panel PROC Full Panel AK1 Protein C receptor ANK1 NT5C3A PROCR EPB42 RHAG Protein S deficiency SPTA1 BPGM PROS1 SPTB GSR Thrombomodulin Autoimmune lymphoproliferative G6PD THBD syndrome GCLC Thrombophilia due to elevated HRG FAS GPX1 HRG CASP10 GSS Tissue factor pathway inhibitor FASLG CD59 TFPI ITK GPI tPA Macrothrombocytopenia PKLR PLAT CD36 KLF1 VTE susceptibility Methemoglobinemia Iron-refractory iron deficiency CYB5R3 anemia HABP2 CYB5A TMPRSS6 Monocyte and dendritic cell Megaloblastic anemia deficiency Full Panel Hematology IRF8 AMN Congenital TTP Neutropenia CUBN ADAMTS13 Full Panel DHFR Elliptocytosis-1 ELANE Pernicious anemia EPB41 GFI1 GIF Erythrocytosis HAX1 Sideroblastic anemia USB1 Full Panel Full Panel Thrombocythemia GLRX5 EPOR THPO SLC25A38 EGLN1 ALAS2 EPAS1 4/1/2014 Version 1 Hemophilia A F8 Hemophilia B F9 Hereditary hemorrhagic Bleeding disorders telangiectasia Afibrinogenemia/dysfibrinogenemia Full Panel Full Panel ACVRL1 FGA ENG FGB SMAD4 FGG Hermansky Pudlak syndrome Alpha-2-Plasmin inhibitor deficiency Full Panel SERPINF2 HPS1 Bernard Soulier syndrome AP3B1 Full Panel HPS3 GP1BA HPS4 GP1BB HPS5 GP9 HPS6 Bleeding disorder due to P2RX1 DTNBP1 defect BLOC1S3 P2RX1 BLOC1S6 Bleeding disorder, platelet-type, 11 Leukocyte adhesion deficiency GP6 FERMT3 Bleeding disorder, platelet-type, 8 Multiple coagulation factor P2RY12 deficiency Chediak Higashi GGCX LYST MYH9 related platelet disorders Combined factor V and VIII deficiency MYH9 PAI1 deficiency LMAN1 SERPINE1 MCFD2 Platelet alpha/delta storage pool Factor deficiencies deficiency Full Panel F13A1 SELP F13B Scott syndrome F2 F9 ANO6 F5 Thrombocytopenia F7 Full Panel F8 MPL F10 HOXA11 F11 CYCS F12 FLNA Familial platelet disorder with ANKRD26 predisposition to AML RBM8A RUNX1 ABCG5 Fibrinolysis inhibitor ABCG8 MASTL CPB2 GATA1 related disease GATA1 Gray platelet syndrome NBEAL2 4/1/2014 Version 1 .
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