Download Karyotype/FISH and array referral form

NORTH WEST THAMES REGIONAL GENETICS SERVICE
(KENNEDY GALTON CENTRE)
CPA Accredited Laboratory
POSTNATAL CYTOGENETIC TEST - REFERRAL FORM
Samples should be sent promptly to the North West Thames Regional Genetics Service (KGC) to arrive by
4pm. If delays are unavoidable, store specimen at 4 C until posting.
Patient and GP addresses (inc. post codes) are required. Without these, reports may be delayed.
Surname:
Forename:
Address:
Date of birth:
Sex:
Male
Female
NHS No:
Hospital:
Dept:
Postcode:
GP details:
Type
NHS
Private
Consultant:
(Surname in full)
Clinician contact number:
Clinical Genetics no:
High risk of infectious disease?
Y / N If yes, please specify risk (if information not provided, sample will not be
processed):
TEST DETAILS
Reason for request / Clinical indication:
Test(s) Required
Karyotype / FISH
(Chromosome analysis, ?trisomy in newborn,
infertility , follow up requests from laboratory
Specific microdeletion eg 22q11)
Blood in lithium heparin (paed 2ml, adult
5ml)
.
Urgent
Array CGH analysis
(paediatric referrals with developmental delay/
malformations/ dysmorphism)
Routine
Include relevant pedigree details. If pregnant, please include gestation
Date sample taken:
Blood in EDTA (paed 2ml, adult 5ml)
Time sample taken:
Sample type:
Consent statement
It is the referring clinican’s responsibility to ensure that the patient/carer knows the purpose of the test and that DNA samples
will be stored for future testing, audit or quality control purposes unless otherwise advised.
Referring clinician signature: …………………………………………………………………………………..
North West Thames Regional Genetics Service
Level 8, Northwick Park and St Mark’s Hospital
Watford Road
Harrow, HA1 3UJ
Email: [email protected]
General enquiries:
020 8869 3154
Fax:
020 8869 5061
Email:
Version: 7 (April 2016)
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