GENETICS LABORATORY SERVICES TEST REQUEST JB: 91148 PATENT NO. 2221208 B Accredited Medical Laboratory Reference No. 2016/1751 HAVE YOU LABELLED THE SPECIMEN CORRECTLY? A JONES & BROOKS EASISEAL SPECIMEN FORM CPA Lab No. Nottingham University Hospitals NHS Trust REGIONAL GENETICS LABORATORY SERVICES Please PRINT details clearly in black pen as this form will be scanned. Incomplete or illegible request forms, or inadequately labelled sample containers, may delay processing PATIENT DETAILS (Affix patient label if available): Surname:........................................................................................................................... Report to (surname in full): Date Sample Taken: Department: Sample Taken By: Referring Centre: Date Received: Contact Telephone No: High Risk of Infection? Hepatitis B Hepatitis C HIV Other............................................... Forename(s):..................................................................................................................... Date of Birth: Birth Gender: M / F / U NHS No: Hospital No:....................................... Clinical Genetics No:.......................................... Address:............................................................................................................................ ........................................................................................................................................... GP Name/Code: GP Address/Code: Postcode:........................................... CCG Code:......................................................... Ethnic Origin:..................................... Gestational Age:................................................. Private? Yes / No If Yes, please provide invoice details below Urgent? Yes No If urgent please provide details ........................................................ Reason for Referral/Clinical Details: (Please provide details of relevant Sample Type: Venous Blood Cord Blood Fetal Blood family history including familial mutation(s), if known) Amniotic Fluid CVS Bone Marrow Other........................................................................................................... Molecular Genetics Blood in EDTA Cytogenetics Blood in Li-Hep (DNA Testing) (Chromosomes) Diagnostic Test Karyotype Carrier Test (Family History) FISH Carrier Test (Population Risk) Storage Presymptomatic/Predictive Test Disease/Investigation Required: (If DNA is to be sent to an external DNA Storage Only laboratory please provide details, if known) Array CGH (Microarray) Blood in Both EDTA and Li-Hep (Please also fill in a ‘Genetic Testing for Neurodevelopmental Disorders’ form, which is available from the website) See reverse of card for consent requirements, laboratory contact information and further sample details GENETICS 0115 969 1169 Ext. 55207 0115 962 7711 [email protected] CYTOGENETICS Telephone: 0115 962 7617 or 0115 969 1169 Ext. 56617 Fax: 0115 840 2611 Email: [email protected] SAMPLE REQUIREMENTS: All sample containers must be labelled with at least two unique patient identifiers, usually full name and date of birth. Unlabelled or incompletely labelled samples are not accepted. Blood samples can be stored at 4°C before sending to the department please DO NOT FREEZE All prenatal samples should be sent to department without delay CYTOGENETICS (Chromosomes) Blood Samples - Adults: 2-4ml in Lithium-Heparin - Children: 1-4ml in Lithium-Heparin - Neonates: Minimum of 1ml in Lithium-Heparin - Array CGH: As above in Lithium Heparin and EDTA Saliva/buccal scrape samples - Oragene collection kits. Please contact the laboratory before sending samples. Amniotic fluid - 10-20ml collected aseptically in a sterile universal. Maternal blood samples in EDTA must accompany all amniotic fluid samples. Fresh tissue - Please contact the laboratory before sending these samples. Samples must arrive frozen. Chorionic villus samples - 10-20mg collected aseptically in a sterile universal with heparinised culture medium (available from the Cytogenetics Department). Amniotic fluid/Chorionic villus samples - Referred via the Cytogenetics Department. Maternal blood samples in EDTA must accompany all prenatal samples unless the laboratory already has a maternal sample. Fetal or placental material/products of conceptions - Sample in sterile isotonic saline solution or culture media in a sterile universal or other sealed container. Bone marrow aspirate - Lithium Heparin tube or heparinised medium Tumour/lymph node - Sample in sterile isotonic saline solution or sterile media in a sterile, sealed container Cord blood and Fetal blood samples - In EDTA tubes. Maternal blood samples in EDTA must accompany these samples. Fold MOLECULAR GENETICS (DNA Testing) Blood Samples - Adults & Children: 4-10ml in EDTA (2 blood tubes are required for presymptomatic testing) - Neonates: Minimum of 1ml in EDTA - Array CGH: As above in EDTA and Lithium Heparin BAG CONSENT: By submitting this sample, the clinician confirms that consent has been taken: a) for testing and possible storage (DNA will be stored indefinitely) b) for the use of this sample and the information generated from it to be shared with members of the donor’s family and their health professionals (if appropriate) PLACE SPECIMEN IN BAG REMOVE COVERING STRIP FOLD TOP OVER TO SEAL www.nuh.nhs.uk/genetics MOLECULAR Telephone: Fax: Email: GENETICS LABORATORY SERVICES TEST REQUEST Regional Genetics Laboratory Services Nottingham University Hospitals NHS Trust City campus Hucknall Road Nottingham NG5 1PB
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