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Hematology Test Requisition

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Hematology Test Requisition GENETICS AND GENOMICS DIAGNOSTIC LABORATORY Mailing Address: For local courier service and/or inquiries, please contact 513-636-4474 • Fax: 513-636-4373 3333 Burnet Avenue, Room R1042 www.cincinnatichildrens.org/moleculargenetics • Email: [email protected] Cincinnati, OH 45229 HEMATOLOGY TEST REQUISITION All Information Must Be Completed Before Sample Can Be Processed PATIENT INFORMATION ETHNIC/RACIAL BACKGROUND (Choose All) Patient Name: _____________________, ___________________, ________ European American (White) African-American (Black) Last First MI Native American or Alaskan Asian-American Address: _____________________________________________________ Pacific Islander Ashkenazi Jewish ancestry _____________________________________________________ Latino-Hispanic _____________________________________________ Home Phone: _________________________________________________ (specify country/region of origin) MR# __________________ Date of Birth ________ /________ / ________ Other ____________________________________________________ (specify country/region of origin) Sex: Male Female BILLING INFORMATION REFERRING PHYSICIAN o REFERRING INSTITUTION Physician Name (print): _________________________________________ Institution: ____________________________________________________ Address: ____________________________________________________ Address: _____________________________________________________ Phone: ( _______ ) _______________ Fax: ( _______ ) _______________ City/State/Zip: _________________________________________________ Email: ______________________________________________________ Accounts Payable Contact Name: __________________________________ Genetic Counselor/Lab Contact Name: _____________________________ Phone: ______________________________________________________ Phone: ( _______ ) _______________ Fax: ( _______ ) _______________ Fax: _________________________________________________________ Email: ______________________________________________________ Email: _______________________________________________________ _______________________________________ Date: ____/ _____/ ____ Referring Physician Signature (REQUIRED) INDICATIONS/DIAGNOSIS/ICD-10 CODE SAMPLE/SPECIMEN INFORMATION Reason for Testing: Has patient received a bone marrow transplant? Yes No o Diagnosis in symptomatic patient Note: For post-transplant patients, we accept pre-transplant samples or o Asymptomatic infant with abnormal newborn screen post-transplant skin fibroblasts ONLY (blood, saliva, and cytobrushes are not accepted). Culturing of skin fibroblasts is done at an additional charge. o Carrier (Heterozygote) testing o Presymptomatic diagnosis of at-risk sibling SPECIMEN TYPE: Amniotic fluid Blood Cytobrushes CVS o Prenatal testing (by previous arrangement only) Cord blood Bone marrow Tissue (specify): ___________________ o Family history of disease Specimen Date: _______ / _______ / _______ Time: ________________ o Other: ____________________________________________________ Specimen Amount: ____________________________________________ WE ARE UNABLE TO ACCEPT BLOOD SAMPLES COLLECTED WITHIN TWO CLINICAL HISTORY WEEKS OF A TRANSFUSION. Please call before sending tissue samples. DRAWN BY: _________________________________________________ o Hepatomegaly o Skeletal abnormalities *Phlebotomist must initial tube of specimen to confirm sample identity. o Splenomegaly o Other positive findings l Single gene tests require at least 3mL whole blood in EDTA. Has patient received a bone marrow transplant? Yes No l Panels require at least 5 mL whole blood in EDTA. If yes, date of bone marrow transplant ______________________________ l Hemoglobin Disorder tests require TWO tubes of whole blood in EDTA Percent engraftment ____________________________________________ (preferably a 5mL and a 2mL, 7mL total). Ship refrigerated. Patient Name: _______________________________________________________ Date of Birth: _________________ MEDICAL HISTORY PEDIGREE OR FAMILY HISTORY Clinic notes and laboratory data attachment, in lieu of writing in medical Parental Consanguinity o Y o N history, is also acceptable. Patient’s medical history: _________________________________________ ____________________________________________________________ ____________________________________________________________ Date of last transfusion: __________________________________________ We are unable to accept blood samples collected within 2 weeks of a transfusion Provisional Hb Diagnosis (for Hemoglobin Disorder tests): ________________ _____________________________________________________________ _____________________________________________________________ For Hemoglobin Disorders testing, please provide a copy of the following laboratory test results, as available: CBC, Hemoglobin electrophoresis, and iron studies. TEST(S) REQUESTED Hemoglobin Disorders Hemolytic Anemia Collect TWO tubes of whole blood: 5mL EDTA and 2mL EDTA. Ship refrigerated. o Hemolytic Anemia Panel (includes sequence analysis of ABCG5, ABCG8, AK1, A hemoglobin electrophoresis is included as part of the Hemoglobin Disorders ALAS2, ALDOA, ANK1, ATP11C, C15orf41, CDAN1, COL4A1, EPB41, EPB42, G6PD, assays to aid the interpretation of genetic results. Charges may apply. GATA1, GCLC, GPI, GPX1, GSR, GSS, GYPC, HK1, KCNN4, KIF23, KLF1, LPIN2, o Alpha (HBA1/2) and Beta (HBB) Globin Gene Locus Analysis NT5C3A, PFKM, PGK1, PIEZO1, PKLR, RHAG, SEC23B, SLC2A1 (GLUT1), SLC4A1, SPTA1, SPTB, TPI1, XK) o HBA1 and HBA2 (α-globin) sequence analysis Reflex to deletion/duplication of entire panel† o HBA1 and HBA2 (α-globin) locus del/dup analysis (HBA1/2 & HBZ) Reflex to deletion/duplication of single gene(s) (specify): ________________ o HBB (β-globin) sequence analysis _____________________________________________________________ o HBB (β-globin) locus del/dup analysis (HBB, HBD, HBG1/2, & HBE) o Congenital Dyserythropoietic Anemia (CDA) Panel (includes sequence analysis o HBD (Δ-globin) sequence analysis of ALAS2, C15orf41, CDAN1, GATA1, KIF23, KLF1, LPIN2, SEC23B) Reflex to deletion/duplication of entire panel† o HPFH Gene Analysis Reflex to deletion/duplication of single gene(s) (specify): ________________ o HBG1 and HBG2 (γ-globin) sequence analysis _____________________________________________________________ o HBB (β-globin) locus del/dup analysis (HBB, HBD, HBG1/2, & HBE) o Reflex to Hemolytic Anemia Panel reanalysis, if indicated o HPFH SNP analysis (polymorphisms in BCL11A, HBS1L-MYB, & KLF1) o RBC Membrane Disorders Panel (includes sequence analysis of ABCG5, ABCG8, Thrombophilic Disorders ANK1, ATP11C, COL4A1, EPB41, EPB42, GYPC, KCNN4, PIEZO1, RHAG, SLC2A1, o Factor V (Leiden) SLC4A1, SPTA1, SPTB, XK) † o MTHFR (677 C>T and 1298 A>C) genotype Reflex to deletion/duplication of entire panel Reflex to deletion/duplication of single gene(s) (specify): ________________ o Prothrombin (Factor II) G20210A genotype _____________________________________________________________ o Thrombophilic polymorphism panel (Factor V- Leiden and o Reflex to Hemolytic Anemia Panel reanalysis, if indicated Factor II-Prothrombin G20210A) o RBC Enzymopathy Panel (includes sequence analysis of AK1, ALDOA, G6PD, Platelet Disorders GCLC, GPI, GPX1, GSR, GSS, HK1, NT5C3A, PFKM, PGK1, PKLR, TPI1) Platelet Disorders Gene Sequencing Panel Reflex to deletion/duplication of entire panel† (ABCG5, ABCG8, ACBD5, ACTN1, ANKRD26, ANO6, AP3B1, AP3D1, ARPC1B, Reflex to deletion/duplication of single gene(s) (specify): ________________ BLOC1S3, BLOC1S6, CD36, CYCS, DIAPH1, DTNBP1, ETV6, FERMT3, FLI1, _____________________________________________________________ FLNA, FYB1, GATA1, GFI1B, GP1BA, GP1BB, GP6, GP9, HOXA11, HPS1, HPS3, o Reflex to Hemolytic Anemia Panel reanalysis, if indicated HPS4, HPS5, HPS6, ITGA2, ITGA2B, ITGB3, LYST, MASTL, MECOM, MPIG6B, Erythrocytosis MPL, MYH9, NBEA, NBEAL2, ORAI1, P2RX1, P2RY1, P2RY12, PLA2G4A, o Erythrocytosis Gene Sequencing Panel PRKACG, PTGS1, RAB27A, RASGRP2, RBM8A, RUNX1, SLFN14, STIM1, (BPGM, EGLN1, EPAS1, EPOR, HBA1, HBA2, HBB, JAK2, VHL) STX11, STXBP2, TBXA2R, TBXAS1, THPO, TUBB1, UNC13D, VIPAS39, VPS33B, Reflex to deletion/duplication of entire panel† VPS45, WAS) Reflex to deletion/duplication of single gene(s) (specify): ______________ † o Reflex to deletion/duplication of entire panel __________________________________________________________ o Reflex to deletion/duplication of single gene(s)† (specify): _______________ Thrombocytosis ____________________________________________________________ o Thrombocytosis Gene Sequencing Panel (CALR, JAK2, MPL, THPO) Reflex to deletion/duplication of entire panel† Reflex to deletion/duplication of single gene(s) (specify): ______________ _________________________________________________________ Patient Name: _______________________________________________________ Date of Birth: _________________ TEST(S) REQUESTED, CONTINUED Targeted (family specific) variant analysis for _____________________ gene Note: Any gene in the panels listed may be ordered individually through custom If testing was not performed at CCHMC, please include proband’s report gene sequencing. and at least 100ng of proband’s DNA to use as a positive control. †Deletion/Duplication analysis of FERMT3, GP6, GP9, HPS5, HPS6, MPIG6B, Proband’s name ___________________________________________________ PTGS1 and P2RY1 is not available at this time. Proband’s DOB ____________________________________________________ Proband’s variant __________________________________________________
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