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