WPC 2EBIJX Z|xTimes New Roman (TT)Arial (TT)Courier New (TT)Monotype Sorts (TT)C\  P6QPJ2PQP"d6X@DQ@4}'' PV/QP2m?wekphoenix#C\  P6QP# Outside Specimen Referral Form John Brent WallisOncology Cytogenetics Lab  2YwDefault Paragraph FoDefault Paragraph Font11#XP\  P6QXP##C\  P6QP#headerheaderX` hp x (#Xhx (#% XXhx (#% X` hp x (#XfooterfooterX` hp x (#Xhx (#% XXhx (#% X` hp x (#X XX  XX headerX` hp x (#Xhx (#% X#2PQP# Oncology Cytogenetics Laboratory  1~!((#XXH#dd#;2PQP#Emory University Hospital 1364 Clifton Road, N.E., Room FG03Phone404/7125833 Atlanta, Georgia 30322Fax404/7124349header~ڐXhx (#% X` hp x (#%XX#C\  P6QP# ĒX` hp x (#X` hp x (#%X#I2PQP# #2PQP# Specimen Referral Form  #I2PQP# Please complete the ENTIRE form. The information requested is needed for registration and billing purposes.  X8%҇1!(XXdd#XX2PQXP# Specimen Information #I2PQP# Date Obtained:________________________________ Time Obtained:________________________________ Specimen Type: #|'' PV/QP#o#I2PQP#Bone Marrow #|'' PV/QP#o#I2PQP#Peripheral Blood (% blasts _______ ) #|'' PV/QP#o#I2PQP#Other (Please be specific) ________________________________ Marrow/Blood:use media tube from Cytogenetics Lab or a green top Sodium Heparin Tube. Solid Tissue:use media tube from Cytogenetics Lab or sterile saline without preservatives. ڐ 1qA(XXdd#XX2PQXP# Referring Information #I2PQP# Institution:_________________________________ Phone Number:_________________________________ Physician:_________________________________ Physician Ph#:_________________________________ Fax:_________________________________ Add. Reports to:_________________________________ _________________________________ qڐ 1a(XXdd#XX2PQXP# Patient/Billing Information  #I2PQP# Name:_________________________________ Address:_________________________________ _________________________________ Sex:_____Date of Birth: ______________ SS#:_________________________________ ID/Record#_________________________________ #|'' PV/QP#o#I2PQP#Bill Institution (contracted accounts only) #|'' PV/QP#o#I2PQP#Bill Medicare/Patient Insurance (Please attach insurance information) Fill in above information or place information label above.ڐ 1T(XXdd#XX2PQXP# Diagnosis/Patient History Information #I2PQP# Dx:________________________________________ ICD#QptQ#!#I2PQP#9:______________________ (for internal use only) #|'' PV/QP#o#I2PQP# New Dx? #|'' PV/QP#o#I2PQP# Remission? #|'' PV/QP#o#I2PQP# Relapse? #|'' PV/QP#o#I2PQP# Post BM Transplant #|'' PV/QP#o#I2PQP# Post Chemoterapy Other Important Patient Information: ________________________________________ ________________________________________ Tگ 1"((#XXH#dd#XX2PQXP# Testing Authorization  Cytogenetic Testing #I2PQP# Submission of this form with signature below authorizes#|'' PV/QP#o#I2PQP# Cell Culture88237 the Oncology Cytogenetics Laboratory to perform#|'' PV/QP#o#I2PQP# Chromosome Analysis88262 cytogenetic testing. #|'' PV/QP#o#I2PQP# FISH/Molecular Testing88283 #|'' PV/QP#o#I2PQP# Heteromorphisms(Baseline)88283 Authorization:_________________________________#|'' PV/QP#o#I2PQP# Heteromorphisms(FollowUp)88283 "