Oncology 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.
 
 
Sex  
 
Bill to:  

 
Chromosome Study:           
FISH Study:           
    source: 
    source: 
    source: 
Lymphoid FISH Disorders:
Acute lymphoblastic leukemia:
Small B-cell leukemia/lymphomas:
Follicular/Large B-cell/High-grade lymphomas:
Plasma cell myeloma:
T-cell lymphomas:
Myeloid FISH Disorders
Myeloproliferative neoplasm:
Myelodysplastic syndrome:
Eosinophilia:
Acute myeloid leukemia:
Solid tumors:
Breast cancer (paraffin embedded):
Specimen origin:
Block Number:
Histologic type:
Cold ischemia time:
Time in formalin: