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Constitutional Request Form

 

Hennepin Healthcare
Cytogenetics Laboratory

701 Park Avenue, Mpls., MN 55415

Please call the laboratory when sending a specimen: phone: 612-873-8548 pager: 612-268-6234.

 
Patient Information
Sex:
Bill to:

DIAGNOSIS
Chromosome Study:
FISH Study:
 
FISH for partial molar pregnancy (13, 18, 21, X, Y)
Microarray: