here - Great Ormond Street Hospital Laboratory Medicine

Paediatric Malignancy Unit
Great Ormond Street Hospital NHS Trust
Cytogenetic and Molecular Diagnostic Services
SAMPLE REQUEST FORM
NAME
SEX
F M
SAMPLE TYPE VOLUME DATE AND TIME TAKEN
DOB Histopathology ID/Lab Reference HOSPITAL NUMBER
Test Requested
NHS NUMBER
CONSULTANT NAME
CLINICAL DETAILS:
Karyotyping and FISH analysis
for leukemia, lymphoma,
Mutation Detection by Direct Sequencing:
ELA2
multiple myeloma and solid tumours
HAX1
NAME AND ADDRESS OF REFERRING HOSPITAL
FFPE FISH
SMARCB1
GATA1
KRAS
Translocation Detection:
NRAS
Leukemia
PTPN11
Sarcoma
CBL
KIAA1549-BRAF
cKIT
Lymphoma
PDGFRa
TP53
CONTACT TELEPHONE NUMBER
AND EMAIL ADDRESS
PRIORITY:
URGENT/ROUTINE
Other:
B-catenin
BRAF
GNAS
WT1
WTX
IDH1
IDH2
JAK2
FOXF1
CONTACT FAX NUMBER FOR REPORT
PATIENT CONSENT
Has consent been given for:
Testing for this referral reason?
YES/NO
MLPA:
Neuroblastoma kit 251and 252
SMARCB1 Kit 258
Please tick as appropriate. Please contact the lab for new tests.
Pease send samples to: Telephone 020 7405 9200 ext. 5762/5755
PMU, Level 2 Camelia Botnar Laboratories Fax 020 7829 8803
Great Ormond Street Hospital NHS Trust
Great Ormond St
London WC1N 3JH

Paediatric Malignancy Unit
Great Ormond Street Hospital NHS Trust
Cytogenetic and Molecular Diagnostic Services
SAMPLE REQUEST FORM
INSTRUCTIONS:
Bone marrow and blood samples for Karyotyping and
FISH analysis:
Any other sample:
Please send 5 mls in preservative free
heparin.
Sample must be labelled with patient name,
DOB and hospital number.
Date and time taken must be written on the
sample and request form.
Mix sample well to prevent clotting.
Please phone the lab for advice.
Samples for karyotyping and RT-PCR must reach the
laboratory within 24 hours of being taken. All other
samples can be sent by 1 st class post.
Blood samples for mutation detection
and MLPA analysis:
Please send 5 mls in EDTA or
preservative free heparin.
Sample must be labelled with
patient name, DOB and hospital
number.
Date and time taken must be
written on the sample and
request form.
Mix sample well to prevent
clotting.
DNA for mutation detection and
MLPA analysis:
Please send a minimum of 10ug
of DNA to perform mutation
detection.
Please ensure a minimum of 2
unique identifiers on the DNA
tube.
Blood and Bone marrow samples for RT-PCR analysis
5 mls in preservative free heparin.
Sample must be labelled with patient name, DOB and hospital number.
Date and time taken must be written on the sample and request form.
FFPE material for FISH and RT-PCR:
FFPE section on slides should be between 2-4uM thick.
Please send a minimum of 4 slides with a minimum of 2 unique identifiers.
For RNA extraction please send 5-10 rolled sections (5-10 uM thick) in an eppendorf
with a minimum of 2 unique identifiers.
Patient Consent Clarification:
Under the Human Tissue Act 2004 informed patient consent is required for all tests from all
patients, and for storage of RNA, DNA and relevant material from DECEASED patients.
Cell suspensions, slides, RNA and DNA from LIVING patients may be stored without
consent for the following purposes (patients should be made aware of this): Audit,
education and training, performance assessment, quality assurance and anonymised
research.
Pease send samples to: Telephone 020 7405 9200 ext. 5762/5755
PMU, Level 2 Camelia Botnar Laboratories Fax 020 7829 8803
Great Ormond Street Hospital NHS Trust
Great Ormond St
London WC1N 3JH