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: