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Cytogenetic Diagnostic Services
Requisition Form

Great Lakes Genetics
2323 North Mayfair Road l Milwaukee, WI 53226-1504
Office: (800) 647-0089 l Laboratory: (414) 475-5904
FAX: (414) 475-7220

Please complete all information and return form to GLG. Feel free to call our lab with any questions.
Date/Time Sample Drawn
(mm/dd/yyyy):		  
Client Information
Physician Name:  
Phone:  
Clinic/Laboratory:  

Address:

 

  
Medical Record #:

 

Patient Information
Patient Name:  
Date of Birth (mm/dd/yyyy):  
Gender: Male
Female


Specimen Submitted (Room Temperature):

Amniotic Fluid (15ml in 2 sterile screw-top tubes) Gestational Week: ___________
Chorionic Villi (15 -25 mg villi in sterile tissue culture media in a screw-top tube)
Products of Conception (0.5- 1.0 cm³ placenta (chorionic villi) and/or 0.5 - 1.0 cm³ of fetal skin + thigh muscle in sterile saline or tissue culture transport media)
Skin (sterile 3-4 mm diameter full thickness punch biopsy in sterile saline or tissue culture transport media)
Blood (7ml {2ml for infants} in sodium heparin green Vacutainer™)
Bone Marrow (2ml marrow in sodium heparin green Vacutainer™ or (2 ml marrow with 0.3ml sodium heparin in red Vacutainer™)
Lymph Node (Sterile center slice or wedge of node placed in sterile saline or tissue culture transport media)
Other Tissue (Specify): _____________________
To obtain sterile culture transport media, please call 414-475-5904

 

Indication:
Intrauterine Growth Retardation
Developmental Delay
Delayed Puberty
Ambiguous Genitalia
Short Stature
Familial Chromosome Rearrangement
Anomalies (Specify): __________________________
Hermatologic Malignancy (See Below)

Infertility

Recurrent Miscarriages
Advanced Maternal Age
Abnormal Maternal Serum Screen
Fetal Demise
Other (Specify): _____________________________

Fluorescent in situ hybridization Probe: _____________________
Molecular DNA Studies (please contact lab) ________________

 

Cancer Cytogenetics:

Previous Cytogenetic Abnormality: _________________________
(For Cancer Cytogenetics, please include copy of patient's recent CBC with differential.)

Suspected Diagnosis Known Diagnosis
S/P Chemotherapy/Radiation Suspected Secondary Malignancy



 

Myeloproliferative Disorders
  Chronic Myelogenous Leukemia
  Other (Specify): _____________________________________
Myelodysplastic Syndrome
Acute Myelogenous Leukemia
  M ______________________________ (FAB Subtype, if known)
Acute Lymphocytic Leukemia
  L ______________________________ (FAB Subtype, if known)

Chronic Lymphoproliferative Disorders
  CLL (For CLL send blood in sodium heparin)
  Other (Specify): _____________________________________
  T-Cell (if known)
  B-Cell (if known)
Lymphoma
Hodgkin
Non-Hodgkin
  Low/Grade
  Intermediate Grade
  High Grade B-cell T-cell

updated 12/05