Fragile X Syndrome (FMR1), DNA Assay
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Fragile X Syndrome (FMR1), DNA Assay | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
LAB3425
Specimen Type:
Blood
Collection Volume:
Blood: 2 mL collected in a Purple Top- EDTA Tube (0.5 mL minimum)
Cause for Rejection:
Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Hemolyzed
Specimen Clotted
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Sample Exceeds Holding Time
Storage:
Refrigerated
Availability:
Mon-Fri (7:30-16:00)
Methodology:
Polymerase Chain Reaction (PCR), Capillary Electrophoresis
Special Instructions:
Include pertinent medical findings on the requisition with suspected diagnosis and/or indication(s) for testing.
Lab/Phone:
330-543-8722
TAT:
10-14 days
CPT Code:
81243
Synonyms:
MartinBell Syndrome
FRAXA
FX
FRAXA
FX
