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Paediatric Malignancy Unit
Great Ormond Street Hospital NHS Trust
Cytogenetic and Molecular Diagnostic Services
Accredited Medical Laboratory
Reference No: 15189
SAMPLE REQUEST FORM
NAME
SEX
F M
DOB Histopathology ID/Lab Reference HOSPITAL NUMBER
SAMPLE TYPE VOLUME DATE AND TIME TAKEN
Test Requested
CONSULTANT NAME
CLINICAL DETAILS:
Karyotyping and FISH analysis
for leukemia, lymphoma,
multiple myeloma and solid tumours
Mutation Detection by Direct Sequencing:
ELA2
HAX1
SMARCB1
NAME AND ADDRESS OF REFERRING HOSPITAL
FFPE FISH
GATA1
KRAS
Translocation Detection:
NRAS
Leukemia
PTPN11
Sarcoma
CBL
KIAA1549-BRAF
cKIT
Lymphoma
PDGFRa
TP53
Other:
WT1
CONTACT TELEPHONE NUMBER
AND EMAIL ADDRESS
PRIORITY
URGENT
ROUTINE
B-catenin
BRAF
GNAS
JAK2
WTX
IDH1
IDH2
FOXF1
MLPA:
CONTACT FAX NUMBER FOR REPORT
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
Accredited Medical Laboratory
Reference No: 15189
SAMPLE REQUEST FORM
INSTRUCTIONS:
Bone marrow and blood samples for Karyotyping and
FISH analysis:
• 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.
Any other sample:
• 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.
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