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Requisition Form

Great Lakes Genetics
2323 North Mayfair Road l Milwaukee, WI 53226-1504
Office: (800) 988-3559 l Laboratory: (414) 475-7984
FAX: (414) 475-7220

Please complete all information and return form to GLG. Feel free to call our lab with any questions.

Patient Information
Suspected Diagnostic/Clinical Information:  
Date (mm/dd/yyyy):  
Patient Name:  
Date of Birth (mm/dd/yyyy):  
Your Patient ID# (if desired):  
Referring Physician:  
Address to send report:  
Address to send invoice:  

Ethnic Origin:
Caucasian
African American
Hispanic
Asiatic
American Indian
Other


Sample Information
Sample Type:
Date Sample Obtained (mm/dd/yyyy):
Blood (1-2 x 5-7 ml EDTA (Purple Vacutainer / 1 X 3 ml EDTA [newborn/infant only])
Amniotic fluid (volume required dependent on assay, typically 15 cc)
Chorionic villi ( 5-10 mg in PBS/medium)
Amniocytes (at least one confluent T25 required)
Other (Please consult with GLG)

Indication:
Confirmation of Diagnosis
Carrier Status
Prenatal Testing
Date of LMP:

Family History? (Please FAX or enclose pedigree with samples)
Yes
No
If Yes, please answer the following questions:
Relationship:
Are there samples already at GLG?
Yes: File or GLG ID#:
No