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Molecular 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 Sample Drawn
(mm/dd/yyyy):		  
Specimen Type: Amniotic Fluid
Blood
CVS
Other: _________________
Client Information
Physician Name:  
Phone:  
Clinic/Laboratory:  
Medical Record #:

 

Patient Information
Patient Name:  
Date of Birth (mm/dd/yyyy):  
Gender: Male
Female
Clinical Information:  
Ethnic Origin: NW European Caucasian
S European Caucasian
Mixed European Caucasian
Ashkenazic Jewish
Other Jewish
Hispanic
African American
Native American Indian
Asiatic
Other: _______________________
Indication for Testing:

Symptomatic
Family history: Mutation known YES (Please attach pedigree) NO
General Population Screening

Molecular Diagnostic Service Requested:
Achondroplasia
Angelman Syndrome
Congenital Adrenal Hyperplasia
Cystic Fibrosis
Dentatorubral Pallidoluysian Atrophy
Duchenne/Becker Muscular Dystrophy
Factor V Leiden
Fragile X Syndrome
Friedreich's Ataxia
Hemochromatosis
Huntington's Disease
Myotonic Dystrophy
Neurofibromatosis
Prader Willi Syndrome
Sexing
Sickle Cell Anemia
Telomere FISH
Other: _____________________
(Consult Great Lakes Genetics prior to sending specimen)

updated 12/05