EMORY GENETICS LABORATORY TEST REQUISITION FORM - Page 1 of 1
2165 N. Decatur Rd., Atlanta, GA. 30033 ▪ (404)778-8500 or 1-800-366-1502 ▪ FAX (404) 778-8559 ▪ www.genetics.emory.edu
PATIENT INFORMATION:
SPECIMEN INFORMATION:
Last Name __________________First_____________________MI_______
Date Collected_______/_______/_______Time_______:_______AM/PM
Parents Names (if pt is a minor)____________________________________
SAMPLE TYPE:
DOB______/________/________
Gender: Male
Female
Unknown
__ Blood(B)
_X__ Saliva Sample
_____Other ___________________________
Mailing Address________________________________________________
City______________________________State_______Zip______________
Preferred Phone# (_________)___________-________________________
REASONS FOR REFERRAL: (check all that apply)
Is this #: Home
_X__Family history of __Fabry Disease_(272.7)
___ Other ____________________________
Work
Cell
Other: ____________________________
Other # where pt. can be reached: (
Ethnicity of Pt. (circle all that apply):
Caucasian/NW European
Jewish-Ashkenazi
Native American
Other
)
-
.
African-American
Asian
East Indian
Hispanic
Jewish-Sephardic
Mediterranean
Native Hawaiian/Other Pacific Islander
PREVIOUS LAB RESULTS:
See attached report with identified family mutation
SPECIAL INSTRUCTIONS:
Fabry Family Member Testing project (AAKP)
PHYSICIAN ORDERING TEST:
Paperwork to be reviewed by genetic counselor
Name________________________________________________________
[ ] Please mark this box if you do NOT want to be
contacted about future Fabry related research studies.
Practice Name_________________________________________________
Address______________________________________________________
City______________________________State_______Zip______________
BILLING INFORMATION:
Preferred Phone# (_________)___________-________________________
Fabry Family Member Testing project, bill to
American Association of Kidney Patients
(client number 4926)
FAX# (__________)____________________________________________
Genetic Counselor_______________________Phone__________________
Molecular Test
DUPLICATE REPORTS TO:
Name____Dawn Laney, MS, CGC_______________________________
_________
Address__Emory LSDC, 2165 North Decatur Road______________
City_____Decatur___________State__GA___Zip___30033____
Preferred Phone# (_404__)___778___-___8518__________
FAX# (__404__)___778-8562______________________________
Rec/d____/____/0__ Unboxed by________________Sender:______________________
TEMP
SPECIMEN
COLOR
#TUBES
COMPLETE
R C F
PT. DATA
R C F
TEST DATA
R CF
LABELS
THIS BOX FOR LAB USE ONLY
INC
NOTES:
Fabry Family Member Testing (KM):
Targeted mutation testing for
previously identified family mutations.
(A report of the family mutation must
accompany submitted sample)