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Cytogenetics Request Form - 49.62kb PDF

1. ie CYTOGENETICS INSTITUTE OF GENETIC MEDICINE S eee CENTRAL PARKWAY NEWCASTLE UPON TYNE NE1 3BZ Rie heel pean N TEL 0191 241 8700 FAX 0191 241 8713 Q 3 A PATIENT S SURNAME SAMPLE TYPE SEE OVER FOR INSTRUCTIONS FORENAME 9 S M F CLINICAL DETAILS AND REASON FOR REFERRAL 7p PATIENT S ADDRESS F POSTCODE W HOSPITAL WARD a HOSPITAL No NHS No W CONSULTANT REPORT TO e QR PRAGTICE See any NHS PRIVATE Oo IF AGED UNDER 16 PLEASE GIVE MOTHER S NAME D O B gt NHS No Samples will be processed only if full information is given Oo FOR LABORATORY USE In submitting this sample the clinician confirms that consent for the investigations requested has been obtained Date of Specimen a Signature Print Name g Cotact NOs inonsan a A CYTOGENETICS LABORATORY NOTES For G banding in patients with possible trisomies including Down syndrome sex chromosome investigations or infertility please send 5ml venous blood in a LITHIUM HEPARIN tube to arrive the same or next day For array CGH in patients with e g developmental delay and or dysmorphic features please send at least 2ml blood in EDTA Array CGH will identify copy number changes at a higher resolution than G banding Array CGH will NOT detect balanced rearrangements and has limited sensitivity for the detection of mosaicism For all URGENT referrals such as newborn babies please send a minimum of 2ml blood in LITHIUM HEPARIN and 1m
2. received Fetuses not requiring a post mortem will be returned to the referring hospital ER POC will be cremated by the RVI unless alternative instructions are received 0191 241 8796 Copies of the user manual may be requested by telephone 0191 241 8700 or downloaded from http www newcastle hospitals org uk services northern genetics aspx CYTOGENETICS INSTITUTE OF GENETIC MEDICINE CENTRAL PARKWAY NEWCASTLE UPON TYNE NE1 3BZ TEL 0191 241 8700 FAX 0191 241 8713 ANUS WAS ANY SVE OLNO Q104 dIYLS AAILOSLOYd SAOWSY ADVSYNS LV1d NO 9V4 4J0Vid ANY 9V4 NI YANIVLNOO NAWIDSdS ADV 1d SUJILANADOLAD
3. l blood in EDTA 0191 241 8702 PLEASE DO NOT USE TUBES WITH A CAPACITY OF LESS THAN 2ml Amniotic Fluid Samples 10 20ml in a sterile plastic universal bottle to arrive the same or next day Store at room temperature if kept overnight Details of LMP scan and any relevant obstetric history should be given Inform laboratory when specimens are sent 0191 241 8795 Chorionic Villi In transport medium provided to arrive at the laboratory without delay Details of LMP scan and relevant obstetric history should be given Inform laboratory when samples are sent 0191 241 8795 Bone Marrow Please send in tubes of culture medium provided by Cytogenetics without delay Please ensure same day receipt in laboratory Inform laboratory when samples are sent 0191 241 8703 Solid Tumours By arrangement only 0191 241 8703 Skin Fetuses Fetal Material and Products of Conception IT IS IMPORTANT THAT THE CORRECT SPECIMENS ARE SENT PLEASE CONSULT YOUR PROTOCOLS OR CONTACT CYTOGENETICS IF YOU ARE UNSURE Send smaller samples in sterile saline Send fetuses and large specimens in a clean sterile container If possible send the same day Otherwise store at 4 C overnight Include the placenta with any fetus DO NOT ADD FIXATIVE DO NOT FREEZE Give gestation and details of relevant obstetric history Fetuses requiring post mortem will be forwarded to Pathology at the Royal Victoria Infirmary Newcastle unless alternative instructions are

Cytogenetics Request Form - 49.62kb PDF

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