Requisition
and Consent Forms
To access all the
forms listed below, you will need: Adobe
Acrobat Reader.
Cancellation Policy:
Test orders may only be cancelled if the following procedure
is completed before 5:00pm (central time) the next business
day after the sample is received. Cancellation orders received
after that time cannot be honored, and tests will be performed,
charged, and reports issued. This includes tests cancelled
for billing (financial responsibility) issues:
- Call Client Services 1-800-411-4363 or 713-798-6555 for cancellations or revisions.
- A Test Cancellation/Revision form will be faxed to your institution for an authorized signature. Upon completion, please fax form to 713-798-6584.
Requisition
Forms: |
Updated |
|---|---|
 Mitochondrial -
Mitochondrial Diagnostic Checklist is included |
5/28/08 |
| Biochemical
(PDF) |
6/24/08 |
| Cancer
Cytogenetics (PDF) |
5/9/08 |
| Cancer
DNA (PDF) |
5/9/08 |
| Cytogenetics
(PDF) |
5/9/08 |
| DNA
- Non-Sequencing (PDF) |
6/12/08 |
| Gene
Sequencing (PDF) |
6/24/08 |
| Prenatal
(PDF) |
6/12/08 |
| Prenatal
Chromosomal Microarray Analysis (PDF) |
5/9/08 |
| Consent Forms: | |
| DNA
Consent (PDF) |
|
| Prenatal
Chromosomal Microarray Analysis Consent (PDF) |
|
| Huntington
Disease (HD) Consent Forms - Required |
2/4/08 |
| Institutional Only Forms: | |
| Biochemical
Genetics Laboratory Requisition for Analyte Tests (PDF) |
7/1/07 |
| Biochemical
Genetics Laboratory Requisition for Enzyme Tests (PDF) |
6/24/08 |
| New
York State Only: Cystic
Fibrosis Carrier Panel Requisition with Physician Consent |
4/14/08 |
Other Forms: |
|
| Genetic
Information Authorization (PDF) |
|
| Authorization
for Release of Surgical Tissue and Pathology Report (PDF) -
HNPCC Screening |