Y Microdeletion
| 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. Y Microdeletion | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
YDELT
Test Workstation :
MAYO
Specimen Type:
Whole Blood
Tube Type:
Purple Top (EDTA)
Alternate Tube Type:
ACD B
Collection Volume:
3.0 mL
Minimum Volume:
1.0 mL
Storage:
Ambient
Availability:
Sent to Reference Laboratory
Methodology:
Polymerase Chain Reaction (PCR) and Agarose gel electrophoresis
Special Instructions:
Requires completed Reference Lab paperwork; Do not spin
Lab/Phone:
330-543-8418
TAT:
7-10 days
CPT Code:
81403
Synonyms:
YMICR
