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Alberta Children’s Hospital 2888 Shaganappi Trail NW, Calgary, AB
Hematology (Ped. Collections): 403-955-7382 Diagnostic and Scientific Centre (DSC)
3535 Research Road NW, Calgary, AB Molecular Hematology: 403-770-3699
Cancer Cytogenetics: 403-770-3690 Foothills Medical Centre
1403 - 29 Street NW, Calgary, AB Special Hematology: 403-944-8070
Flow Cytometry: 403-944-4765
BONE MARROW PATHOLOGY REQUISITION
Affix addressograph imprint or patient label to ALL PAGES, or clearly print patient’s full name (last name, first name), date of birth, gender, Personal Health Number and Medical Record Number
ORDERING PHYSICIAN
Last Name:____________________________________________________________
Full First Name:________________________________________________________
Location (Unit/Clinic):___________________________________________________
If Flow Cytometry FAX result to: (Name) ________________________________
(Number ) _______________________________
COPY TO:
1) ______________________ _______________________ ____________________ Last Name Full First Name Office Address (Location)
2) ______________________ _______________________ ____________________ Last Name Full First Name Office Address (Location)
COLLECTED BY: DATE COLLECTED: TIME COLLECTED:
RGH COLLECTED AT:
PATIENT LOCATION:
DATE RECEIVED: PBS # GENERAL LAB ACC LABEL AP ACC LABEL
TIME RECEIVED:
TAT:
Laboratory Information Centre: 403-770-3600 REQ9061BM Rev 2.01
SPECIMEN TYPE: SITE: PREVIOUS SPECIMENS?
Aspirate Biopsy Lt. Iliac Crest Rt. Iliac Crest Sternum Bone Marrow Other, specify: _____________________________________________ No
CLINICAL DIAGNOSIS AND HISTORY: Clinical Diagnosis (check off appropriate boxes):
INITIAL STAGING FOLLOW-UP
Anemia
Pancytopenia
Thrombocytopenia
Leukemia, specify ___________________________
Lymphoma, specify __________________________
Plasma Cell Neoplasm, specify ________________
Myeloproliferative Neoplasm, specify ____________
Myelodysplasia
Other, specify ______________________________
Chemotherapy/Other Therapy:
Date of Last Therapy:
Additional Clinical Information/Special Request
Presence of Serum/Urine Monoclonal Peak:
IgG IgM IgA Kappa
Lambda Other_____________
No Transplanted: Yes
Gender of Donor: Male Female
Procedure Notes:
Clotted Dry Tap Difficult draw
Other______________________________________
HEMATOLOGY/MORPHOLOGY:
BM Bone Marrow Pathology Molecular Hematology DNA Specimen (Initial Bone Marrow)
ADDITIONAL STUDIES: (FOR LAB USE ONLY)
FLOW CYTOMETRY – BONE MARROW MOLECULAR HEMATOLOGY For sorted Chimerism Studies, see Flow Sort
CANCER CYTOGENETICS (CG CYTOGEN)
PAN/MDS - Pancytopenia/Myelodysplasia Panel
LEUK - Leukemia Panel
LOMA - Lymphoma Panel
MM - Plasma Cell Neoplasm Panel
MPD - Myeloproliferative Neoplasms
FLOW SORT
Immunophenotyping
Chimerism Studies – sorted
T cell B cell
Myeloid Other:_______________
DNAR BM Chimerism Studies – Unsorted Recipient Cells
PHLR BM Philadelphia Chromosome Transcript Analysis (Nested PCR)
APL BM APL Transcript Analysis (Nested PCR)
JAK2 BM JAK2-V617F Mutation Analysis
FLT3 BM FLT-3 Mutation Analysis
QPCRPH1 Quantitative PCR Analysis of BCR-ABL1 Fusion Gene Transcripts
NPM1 BM NPM1 Mutation Analysis
MH Misc other ________________________
Chromosomes
FISH
NGS
Hold
For Cancer Cytogenetics use only:
Volume (ml):
Count:
Culture set up:
File Number:
ACH FMC PLC SHC
OTHER: