CYTOGENETIC LABORATORY

University of Kansas Medical Center
1213 University of Kansas Hospital
3901 Rainbow Blvd.
Kansas City, KS 66160-7232
University of Kansas Hospital
Clinical Laboratories
Laboratory: (913) 588-1707
After hours: 588-1700,
beeper #7016
or 588-5000, beeper #7016
 
KUMC Patient Number: Physician:
Patient's Full Name: Mailing Address:
Sex:   F     M     (  ) Married     (   ) Single    DOB:  
Guarantor:  
Mailing Address: Telephone #                         FAX#
Phone  # H)                          W)                  County: Insurance Company:   
Social Security # Address:
Employer:  
Address: Phone #               Group #
  Policy #
Bill to: (   ) Patient/Insurance    (   ) Physician/Hospital Subscriber: DOB (Required)       
ICD-9 CODE:____________________  (REQUIRED)
CLINICAL HISTORY: Include reason for study, dysmorphic features, WBC, etc.


Gestational Age: ___________ Collection time: ___________   Collection date:____________

**KEEP ALL SAMPLES AT ROOM TEMPERATURE**
**BRING TO LAB
BEFORE 3:00 p.m. Mon. - Fri.**

I. Peripheral Blood - Draw 7-10 ml blood into Sodium Heparin;
1-2 ml on newborn
(   ) Routine Congenital
(   ) Routine Hematologic
(   ) High Resolution
(   ) Fragile - X
(   ) Fanconi
II. Bone Marrow: Draw 1-2 ml marrow into Sodium Heparin
(   ) Routine study
III. Amniotic Fluid - 20 ml fluid in sterile, plastic centrifuge tubes
(  ) Routine study
IV. Tissue - Submit in sterile transport media or saline
(   ) Skin Biopsy
(   ) Products of Conception
(   ) Solid Tumor
(   ) Chorionic Villi Biopsy * Special arrangements needed

LAB USE ONLY:

Lab ID No. __________
Date received:___________
Time received:__________

(  ) Specialized Banding
(  ) Nucleic Acid Probe
(  ) Mosaic Study
(  ) Culture maintenance