Medical Science Building, Room F624
Rutgers, The State University of New Jersey
185 South Orange Avenue
Newark, NJ 07103
Cytogenetic Lab:
Biochemical Lab:
Genomics Lab:
Billing:
Fax:
973-972-5937
973-972-3738
973-972-3170
973-972-4612
973-972-0795
CYTOGENETICS & CLINICAL GENOMICS LAB REQUISITION FORM
Patient Information
Name: _______________ _____________ ____
LAST NAME
FIRST NAME
Date of Birth: ____/____/____
MM
DD
MI
Sex: ☐Female
☐Male
YY
Date of Collection: ____/____/_____
MM
DD
YY
Sample Type: ☐Blood
☐Amniotic Fluid ☐POC ☐ Skin Biopsy
☐Other(Specify) _____________
Gestational Age _______ ☐by Ultra Sound ☐ by LMP
LMP_____________
Medical Records#: _______________
Reporting Information
Additional Professional Report Recipients
Physician: _________________________________
Institution:_________________________________
Phone: ________________ Fax:_____________
Name: ___________________________________
Institution:_______________________________
Phone: _______________ Fax: _____________
Indication for Study
Common Pediatric Tests
Perinatal FISH Tests
☐ CBR
☐ CGH 105K
☐ FXMO
☐ F/INT
☐ F/INT
☐F/INT
☐ F/INT2
Chromosome Analysis, Constitutional
SNP Microarray Analysis, Constitutional
Fragile X FMR1 molecular analysis
Common Prenatal Tests
☐ CIS
☐ FISH5
☐ AAFP
☐ CGH 105K
Chromosomal Analysis, Prenatal
AneuVysion Kit (X/Y/13/18/21)
Alpha feto protein
SNP Microarray Analysis, Prenatal
Other Prenatal tests
☐ CMV Amnio
☐ HGB F
☐ TOXPLO P
☐ ACHE
CytoMegaloVirus
Fetal Hemoglobin
Toxoplasmosis by PCR
Acetylcholinesterase
Trisomy 13 (RB1), 13q34
Trisomy 18 (D18Z1), 18cen
Trisomy 21 (LSI 21), 21q22
Sex Determination, CEPX/CEPY
Next Generation Sequencing Tests
☐ CF2000
☐ MITO
CFTR Gene Sequencing
Mitochondrial DNA Sequencing
Other Molecular Genetic Tests
☐
☐
☐
☐
PWS/AS
SMA
HCR
SC
Prader-Willi/Angelman syndrome methylation
SMN1 and SMN2 gene dosage
Hereditary Hemochromatosis
Sickle Cell Disease
Other Tests (Please Specify)
POC/Skin Biopsy Tests
☐ CPOC
☐ CST
☐ CGH 105K
Chromosome Analysis, Product of
Conception
LAB USE ONLY
Chromosome Analysis, Skin/ Fibroblast
SNP Microarray Analysis, POC/Fetal Skin
FISH Tests for Microdeletion Syndromes
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
☐ F/DEL
1p36 (LSIp58)
Angelman (D15S10), 15q11-q13
Cri-du-Chat (CDC), 5p15.2
DiGeorge (HIRA), 22q11.2
Kallman (KAL), Xp22.3
Miller Dieker (LIS1), 17p13.3
Prader-Willi (SNRPN), 15q11-q13
Smith Magenis (SMS), 17p11
Steroid Sulfatase (STS), Xp22.3
Williams (ELN), 7q11.23
Wolf Hirschhorn (WHS), 4p16.1
X/SRY, Xcen/Yp11.3
Genetics #
______________
Lab/Specimen # _______________
Date/Time received _______________
Last Updated: 02/04/2015