Shodair Children’s Hospital Genetics Laboratory 2755 Colonial Dr, Helena. MT, 59601 Phone (406) 444-7532 Toll Free (800) 447-6614 Fax (406) 444-1022 email: [email protected] GENETICS LABORATORY TEST REQUEST FORM Shodair Lab Number PATIENT INFORMATION SAMPLE INFORMATION
Whole Blood ( ≥3mL) ______ Direct Amniotic Fluid Date of Collection______Last Name Cultured Amniocytes (2-T25) Reference #______MI ______ Direct CVS Cultured CVS (2-T25) First Name select all that apply Ethnicity Saliva/Buccal Cells ______/ ______/ ______ Caucasian Extracted DNA (≥10ug) Source:______Date of Birth Asian Fresh/Frozen Tissue Source:______ Hispanic Sex: African American ADDITIONAL FAMILY SAMPLES (EDTA blood/saliva) □ Female □ Male Ashkenazi Jewish Relationship:______Relationship:______ Hutterite American Indian Name:______Name:______ORDERING HEALTH CARE PROFESSIONAL DOB:______Ref #:______DOB:______Ref #:______Date Collected: ______Date Collected: ______Name: ______NPI #: ______Affected: □ Yes □ No Affected: □ Yes □ No Address: ______AUTHORIZATION City, State, Zip: ______By submitting this requisition, I confirm that I have obtained the patient’s Telephone:(_____)______FAX:(_____)______informed consent for the requested test. I confirm that this test is clinically valuable for the patient. Referring Facility:______Additional Reports To: ______Signature of ordering provider Date INSTITUTIONAL BILLING
Institution: ______Billing Contact: ______Address: ______Phone #: ______City, State, Zip: ______Fax #: ______MEDICAID / MEDICARE Name of policy holder: ______Passport ID: ______Policy holder DOB: ______Phone #: ______Address: ______MEDICAID / MEDICARE #: ______City, State, Zip: ______INSURANCE BILLING SELF PAY
Name of policy holder: ______Name of responsible party: ______Policy holder DOB: ______Relationship to patient: ______Phone: ______Patient Relation to Policy Holder: ______Please call the Financial Assistance Coordinator at (406)444-7507 to arrange payment options SS # (Guarantor): ______Address: ______PREAUTHORIZATION ASSISTANCE* City, State, Zip: ______ YES *CLINICAL INFORMATION REQUIRED Phone #: ______ NO Successful preauthorization requires complete clinical information. Ins. Co. Policy #: ______Please designate a contact for preauthorization updates: Name of Ins. Co ______Name:______Ins. Co Phone: ______Phone or email: ______
SHODAIR INTERNAL USE ONLY Med Rec # Date Received Tracking # Sender Initials
GENETICS LAB REV. D 10-2018 Page 1 of 3 Shodair Children’s Hospital Genetics Laboratory 2755 Colonial Dr, Helena. MT, 59601 Phone (406) 444-7532 Toll Free (800) 447-6614 Fax (406) 444-1022 email: [email protected] GENETICS TEST REQUEST FORM Shodair Lab Number Patient Name: ______DOB: ______
REASON FOR TESTING, CLINICAL DIAGNOSIS AND ICD-10 CODES PLEASE INCLUDE SECOND PAGE OF CLINICAL INDICATIONS AND/OR ADDITIONAL CLINICAL INFORMATION, MEDICAL RECORDS, PICTURES, FAMILY HISTORY TO AID IN RESULT INTERPRETATION. Diagnostic Clinical Description: Phenotypic Description: ICD-10 Codes (required): Prenatal Information: Prenatal LMP:______Gestational Age:______ Carrier Screening G_____P_____Ab_____ Family History No Family History Fetal Sex (if known):______CYTOGENETIC TESTS CHROMOSOMAL MICROARRAY (CMA) Acceptable sample types: Sodium heparin blood (green top, Acceptable sample types: EDTA blood (purple top), cultured cells, NOT LITHIUM HEPARIN), direct amniotic fluid, CVS, cultured fresh/frozen tissue—call 406-444-7532 with questions. cells, fresh (unfixed) tissue—call 406-444-7532 with questions. Chromosomal Microarray Chromosomes (Karyotype) NEXT-GENERATION SEQUENCING (NGS) FISH (select at least one of options below) Direct Interphase Aneuploidy (AneuVysion) Acceptable sample types: EDTA blood (purple top), cultured cells, Other ______fresh/frozen tissue —call 406-444-7532 with questions.
For POC/CVS samples, cytogenetic studies cannot determine with certainty that a normal female result is not due to maternal cell con- Gene Panels: tamination. We strongly recommend sending a maternal blood sample Developmental delay, Intellectual disability, Autism (3-5mL EDTA) to rule out maternal cell contamination. This maternal Epilepsy sample will be discarded in the event of an abnormal or male result. Neuromuscular Decline Maternal Cell Contamination Studies Charcot-Marie-Tooth Aortopathy (Marfan syndrome, Loyes-Dietz syndrome, etc.) MOLECULAR GENETIC TESTS Cardiac arrhythmia including Long QT syndrome Acceptable sample types: EDTA blood (purple top), cultured Noonan Syndrome cells, fresh/frozen tissue—call 406-444-7532 with questions. Hearing Loss Order by Clinical Indication: Angelman/Prader-Willi (AS/PWS) Methylation
Beckwith-Wiedemann Syndrome (BWS) Specify Gene(s): KCNQ1OT1 & H19 Methylation Reflex to UPD11 if positive (parent samples required) Fragile X Syndrome (FMR-1) KNOWN FAMILIAL VARIANT STUDIES Hemochromatosis (HFE) Mutations (C282Y / H63D) Huntington Disease (HTT) Mutation Acceptable sample types: EDTA blood (purple top), cultured cells, Maternal Cell Contamination (recommended for CVS) fresh/frozen tissue—call 406-444-7532 with questions. Myotonic Dystrophy Russell-Silver Syndrome (RSS) Copy Number Analysis H19 Methylation Sequence Variant UPD7 (parent samples required) Spinal Muscular Atrophy (SMA) Proband Name______ Thrombophilia Gene Polymorphism Panel Relationship to Proband______ Factor V Leiden Prothrombin MTHFR X-Chromosome Inactivation Variant Description______ Uniparental Disomy Screen (parent samples required) If proband studies were not performed at Shodair, please include Select Chromosome(s) 2, 6, 7, 8, 9, 11, 13, 14, 15, 16, 20, 21 a copy of the proband report Specific Test Instructions (Reflex testing, STAT, etc.)
GENETICS LAB REV. D 10-2018 Page 2 of 3 Shodair Children’s Hospital Genetics Laboratory 2755 Colonial Dr, Helena. MT, 59601 Phone (406) 444-7532 Toll Free (800) 447-6614 Fax (406) 444-1022 email: [email protected]
GENETICS TEST REQUEST FORM Shodair Lab Number Patient Name: ______DOB: ______
CLINICAL INDICATIONS Perinatal history Skin, Hair, & Nail Abnormalities Genitourinary abnormalities (Please check all the apply) Abnormal nails ______ Ambiguous genitalia Prematurity Abnormal pigmentation ______ Hypospadias Intrauterine growth retardation Abnormal connective tissue ______ Hydronephrosis Oligohydramnios Blistering Undescended testis Polyhydramnios Ichthyosis Kidney malformation Cystic hygroma / increased NT Skin tumors/Malignancies Renal agenesis Growth Other: ______ Renal tubulopathy Failure to thrive Brain Malformations/abnormal imaging Other: ______ Growth retardation / short stature Agenesis of the corpus callosum Endrocrine Overgrowth Holoprosencephaly Diabetes mellitus Macrocephaly Lissencephaly Type I Microcephaly Cortical dysplasia Type II Physical/Cognitive Development Heterotopia Hypothyroidism Fine motor delay Hydrocephalus Hypoparathyroidism Gross motor delay Brain atrophy Pheochromocytoma/paraganglioma Speech delay Periventricular leukomalacia Metabolic Intellectual disability Hemimegalencephaly Ketosis Learning disability Abnormalities of basal ganglia Lactic academia/high CSF lactate Developmental regression Other: ______ Elevated pyruvate Behavioral Neurological/Muscular Elevated alanine Autism spectrum disorder Ataxia Organic aciduria Autistic features Chorea Low plasma carnitine Obsessive-compulsive disorder Dystonia CPK abnormalities Stereotypic behaviors Hypotonia Hemotologic/Immunologic Other psychiatric symptoms Hypertonia Recurrent fever Craniofacial/Ophthalmalogic/Auditory Seizures (type: ______) Anemia/neutropenia/pancytopenia Cataracts Spasticity Immunodeficiency Type: ______ Cleft lip/palate Exercise intolerance/easy fatigue Other: ______ Coloboma of eye Muscle weakness CPEO (opthalmoplegia) Stroke/stroke-like episodes Ptosis Recurrent headache/migraine Blindness Gastrointestinal Optic atrophy Gastroschisis/omphalocele Retinitis pigmentosis Pyloric stenosis Hearing loss Tracheoesophageal fistula Ototoxicity (aminoglycoside-induced) Delayed gastric emptying External ear malformation Eosinophilic esophagitis Facial dysmorphism Gastrointestinal reflux Describe: ______ Recurrent vomiting Cardiac/congenital heart malformations Chronic diarrhea ASD Constipation VSD Chronic intestinal pseudo-obstruction Coactation of aorta Hirschsprung disease Hypoplastic left heart Hepatic failure Tetralogy of Fallot Elevated transaminases Cardiomyopathy Skeletal/Limb abnormalities Arrhythmia/conduction defect Contractures Other: ______ Club foot Polydactyly Syndactyly Scoliosis Vertebral anomaly Other: ______
GENETICS LAB REV. D 10-2018 Page 3 of 3