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.

Date:

Patient Information

Patient Name

Date of Birth:

Sex:

Male Female

Client medical record number

Referring physician(s)

Collection date

Collection time

AM or PM

Institution

Bill to:

Account Patient*

*Please attach billing information.

DIAGNOSIS

Chromosome Study:

Blood (Routine chromosome study to look for abnormalities such as Down syndrome, Turner syndrome, Klinefelter syndrome, couples with infertility.)

Amniotic Fluid Gestational age:

Products of Conception/Abortus/Fetal Tissue

Tissue type:

FISH Study:

Blood

4p16.3 Wolf-Hirschhorn

5p15.2 Cri-du-chat

7q11.23 Williams

15q11.2 Prader-Willi, Angelman

17p11.2 Smith Magenis

17p13.3 Miller-Dieker

22q11.2 DiGeorge, Velocardiofacial

Amniotic Fluid, Prenatal FISH (13, 18, 21, X, Y)

Products of Conception/Abortus/Fetal tissue

Tissue type:
FISH for partial molar pregnancy (13, 18, 21, X, Y)

Microarray:

Blood (FDA cleared for patients with developmental delay, intellectual disability, congenital anomalies, and dysmorphic features)

Products of conception/ Abortus/ Fetal tissueTissue type: