REFERRING CLIENT/COLLECTION CENTER
(VPLS) VPLS CLIENT ACCOUNT
Nurse/Amb = VUH-VPLS
vANDERBILT pATHOLOGY LABORATORY SERVICES
(615) 936-0510
Nashville:
•
Continental U.S .:
(800)551-5227
BILL TO:
SEND SPECIMEN(S) TO:
Client Account
Lab Use Only
VUMC Case Label
4607 The Vanderbilt Clinic
1301 Medical Center Drive
Patient (Billing information must be attached .)
Nashville TN 37232-531 0
PATIENT NAME (LAST)
(FIRST)
SEX
DATE COLLECTED
TIME COLLECTED
1- I
SERUM
0
1- I
I
I -I
PLASMA
0
1-1
L . __ _ _ _ _ _ _ _
0
3G
_, (CLIENT)
SAMPLE ID
§ ~~I
URINE
FOR LAB USE ONLY
3G MtU##
PATIENT ID NUMBER
I
PHONE NUMBER
(M.I.)
DATE OF BIRTH
DFEMALE DMALE
I
REFERRING PHYSICIAN
RE~p'flif
3G
.___ _ _ _ _ _ __, (REFERENCE)
OTHER
URINE TOTAL VOLUME
PLEASE INCLUDE COMPLETE PATIENT BILLING INFORMATION (FACE SHEET) WITH SAMPLE
~R=E~FE~R~R~I~N~G~P~A~T~H~O~L~O~G~I~S~T~=------~-----------------------------ICD-10Code: ________________
REQUIRED PATIENT INFORMATION: D i a g n o s i s : - - - - - - - - - - - - - - Date of Original Dx:_ _ _ ___
PATIENT HISTORY:
U AMUMDS
U ALL (Circle B or T)
LJLymphoma
U Plasma Cell Myeloma
[_J Myeloproliferative Neoplasm ,
Specify:
[_J Unknown
U Other:
CLINICAL CONTEXT:
U Initial Visit I Diagnosis
U Follow-Up Visit
U Relapse I Progression- reason
suspected :
GROWTH FACTOR TREATMENT (Within
Last Week):
U Yes UNo
PRIOR TEST RESULTS:
U WBC:-:-------Date/Time: :-::-:-:----U Karyotype I FISH ,
Specify:_ _ _ _ _ _ _ __
U FLT3
-------LJNPM1 _ _ _ _ _ _ __
LJBCRABL_ _ _ _ _ __
[.:.._jJAK-2
SAMPLE SUBMITTED:
Option 1: U
Option 2: U
Option 3: LJ
LJ Bone Marrow Aspirate
LJ Peripheral Blood
LJ Fluid I Tissue
Source: _ _ _ _ _ _ _ _ __
BONE MARROW TESTING PANEL (VU Pathologist will select appropriate tests based upon review of morphology and clinical history)
Please submit bone marrow smear if this option is requested
A LA CARTE TEST ORDERING (Ordering physician select ancillary testing below)
HOLD FOR TESTING (VU Lab: Flow+Grow & Hold) [Client Lab: Fax final orders to 615-343-7961]
CYTOGENETICS
CYG
CHROMOSOME ANALYSIS (Karyotype)
FLOW CYTOMETRY ANALYSIS
FCL
FLOW CYTOMETRY LEUKEMIA I LYMPHOMA
MOLECULAR GENETICS
AML SNAPSHOT PANEL
AMS
IGR
B-CELL CLONALITY (IGH)
B2A
BCRABL mRNA COPY NUMBER
BC2
BCL-2 GENE REARRANGEMENT
BONE MARROW ENGRAFTMENT
RFL
FL3
FL T3 INTERNAL TANDEM DUPLICATION
JK2
JAK2 MUTATION V617F
NPM
NPM1 INSERTION MUTATION
T-CELL CLONALITY
TCC
FISH ANALYSIS -either order panel or individual markers :
Acute Lymphoblastic Leukemia (pre-B ALL Panel)
LLP
_TEL
t(12;21) (TEL-AML1)
_11M
Chr 11q23 (MLL)
_922
t(9;22) (BCR-ABL)
_ 119
t(1;19) (E2A-PBX1)
4, 10 and 17 Centromeres (Hyperdiploidy)
9P21 (CDKN2A)
FLK
Acute Myeloid Leukemia (AML Panel)
821
t(8;21 ) (AML 1-ETO)
_ APL APL: t(15;17) (PML-RARA)
116
inv(16) (MYH1 1-CBFB)
_11M Chr 11q23 (MLL)
MDV
Myelodysplastic Syndrome (MDS Panel)
C5Q Chr 5q
C7Q Chr 7q
C8C Chr 8 (centromere)
200 Chr 20
FISH ANALYSIS CONT'D- either order panel or individual markers:
922
Chronic Myeloid Leukemia (CML): t(9,22)
Chronic Lymphocytic Leukemia (CLL) Panel
LCL
11A Chr 11q23 (ATM)
_ 12C Chr 12 (centromere)
_ MIR Chr 13q14 (miR15-16)
_ P13 Chr 17p13 (p53)
LYM
Lymphoma
FLL Follicular Lymphoma: t(14;1 8)
MAN Mantle Cell Lymphoma: t(11; 14)
MZL Marg inal Zone Lymphoma : t(11 ; 18)
BUR Burkitt Lymphoma : MYC breakapart
ALK ALCL: ALK breakapart
OLP Other Lymphoma : BCL6 breakapart
PMY
Plasma Cell Myeloma (PCM Panel)
MAN t(11 ;14)(CCND1 -IGH )
_ 17C Chr 17p13 (p53)
_ 13C Chr13q14(RB)
414 t(4;14) (FGFR3-IGH)
Other Myeloproliferative Neoplasm : PDGFRA/8
OMN
FISH M IF
FMF
OTH
OTHER (specify): _ _ _ _ _ _ _ _ _ ___
OTHER TESTS
Please write-in test(s) requested:_ _ _ _ _ _ _ _ _ _ __
FOR MORE INFO OR ASSISTANCE:
VMC HEMEPATH : 1-800-551 -5227, x7
VPLS ADMIN OFFICE: 1-800-551-5227 , x3
VISIT VPLS ON-LINE AT: www.labVU.com
Q Vanderbilt Universitv Medical Center
FORM NO. 60-002-664 (REV 07110)