Requisition for Molecular Diagnostic Services

• PLEASE CHECK ALL APPROPRIATE BOXES AND HAVE PATIENT READ AND COMPLETE CONSENT FORM
• This requisition form and the consent form can be printed directly from your WWW browser. The requisition form should be two pages while the consent form should be one page.
• QUESTIONS? PLEASE CONSULT WITH LAB

DATE (MM/DD/YY):__________________________

PATIENT NAME:__________________________________________________

DATE of BIRTH(MM/DD/YY):__________________________

YOUR PATIENT ID# (if desired):__________________________

REFERRING PHYSICIAN:__________________________________________________

ADDRESS TO SEND REPORT:______________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

ADDRESS TO SEND INVOICE:_______________________________________________________________________

______________________________________________________________________________________________

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ETHNIC ORIGIN:

• Caucasian
• African American
• Hispanic
• Asiatic
• American Indian

SAMPLE TYPE:

• Blood (1-2 x 5-7 ml EDTA (PURPLE VACUTAINER / 1 X 3 ml EDTA (newborn/infant only)
• Amniotic fluid (volume required dependent on assay - typically 5 - 7 ml unspun minimum)
• Chorionic villi ( 5 - 10 mg in PBS/medium)
• Amniocytes (at least 1 confluent T25 required)
• Other (Please consult with CompGene)

DATE SAMPLE OBTAINED(MM/DD/YY):__________________________

INDICATION:

• CONFIRMATION OF DIAGNOSIS
• CARRIER STATUS
• PRENATAL TESTING
• Date of LMP:__________________________

FAMILY HISTORY? (Please FAX or enclose pedigree with samples)

• YES If YES, RELATIONSHIP:__________________________
• NO
  

  If you checked YES for FAMILY HISTORY, ARE THERE SAMPLES ALREADY AT CELTEK or CompGene?

• YES If YES, CompGene or CELTEK ID#:__________________________
• NO

• ACHONDROPLASIA (ACH) (FGFR 3)
• alpha-THALASSEMIA
• ANGELMAN SYNDROME (Methylation Analysis - Segregation Analysis also available - contact CompGene)
• APERT SYNDROME (FGFR 2)
• BCR-ABL FUSION GENE TRANSCRIPT - REAL-TIME QUANTITATIVE PCR ANALYSIS (Q-PCR)
• BECKWITH-WIEDEMANN SYNDROME (BWS) (LIT1, H19 and patUPD11 studies)
• beta-THALASSEMIA
• CHARCOT-MARIE-TOOTH TYPE 1A (Contact CompGene)
• CONGENITAL ADRENAL HYPERPLASIA (21-hydroxylase deficiency)
• CORONAL CRANIOSYNOSTOSIS SYNDROMES (FGFR 2 and FGFR 3)
• CROUZON SYNDROME (FGFR 2)
• CYSTIC FIBROSIS
• DNA BANKING
• DUCHENNE/BECKER MUSCULAR DYSTROPHY
• FACTOR V (Leiden)
• FLT3 (ITD and D835 substitutions)
• FRAGILE X SYNDROME
• FRIEDREICH'S ATAXIA
• GALACTOSEMIA (galactose-1-phosphate uridyl transferase (GALT) deficiency)
• HEMOCHROMATOSIS (HFE)
• HEMOGLOBIN C
• HEMOGLOBIN S
• HEMOPHILIA A (Factor VIII) (inversion or linkage analysis)
• HEREDITARY NEUROPATHY with LIABILITY to PRESSURE PALSIES (HNPP)
• HUNTINGTON DISEASE(HD)
• HYPEREKPLEXIA (GLRA1)
• HYPOCHONDROPLASIA (HCH)(FGFR 3
• INCONTINENTIA PIGMENTI (NEMO)
• JAK2 (V617F substitution)
• LEBER HEREDITARY OPTIC NEUROPATHY (LHON)
• MACHADO-JOSEPH DISEASE (SCA3)
• MOLECULAR FINGERPRINTING (MOLAR PREGNANCY)
• MOVEMENT DISORDER MUTATION PANEL
• MUENKE SYNDROME (FGFR 3)
• MYOTONIC DYSTROPHY (DM1)
• MCAD (medium-chain acyl-coA dehydrogenase) DEFICIENCY
• NEONATAL HYPOTONIA PANEL (PWS, DM1 and SMN1 analyses)
• NPM1
• PRADER-WILLI SYNDROME (Methylation Analysis)
• RhD TYPING
• RhC/c TYPING
• RUSSELL-SILVER SYNDROME (RSO) (H19 methylation analysis and matUPD7 studies)
• SEXING
• SICKLE CELL ANEMIA
• SKELETAL DYSPLASIA PANEL (FGFR3 - THANATOPHORIC DYSPLASIA, ACHONDROPLASIA, HYPOCHONDROPLASIA)
• SPINAL MUSCULAR ATROPHY I//II/III Diagnostic deletion testing
• SPINAL MUSCULAR ATROPHY I//II/III Deletion carrier testing
• SPINOCEREBELLAR ATAXIA TYPE 1 (contact CompGene)
• SPINOCEREBELLAR ATAXIA TYPE 2
• SPINOCEREBELLAR ATAXIA TYPE 3
• SPINOCEREBELLAR ATAXIA TYPE 6
• SPINOCEREBELLAR ATAXIA TYPE 7
• SPINOCEREBELLAR ATAXIA TYPE 8
• SPINOBULBAR MUSCULAR ATROPHY (KENNEDY'S DISEASE)
• THANATOPHORIC DYSPLASIA (TD1 AND TD2) (FGFR 3)
• TRANSIENT NEONATAL DIABETES (TNDM)
• UNIPARENTAL DISOMY STUDIES (UPD) Specify chromosome(s) ________________
• WILLIAMS SYNDROME
• ZYGOSITY TESTING
• OTHER (specify)