The lab tests listed below requirethat a completed patient history and/or informed consent form be submitted to ARUP to perform and/or interpret patient results. For the ordered test, please print and fill out the required form(s), then submit with the test request form or electronic packing list.
| Patient History Forms (Required) |
| Test # |
ARUP Test Name |
Required Form (PDF) |
|
|
English |
Español |
| 0051265 |
Achondroplasia, Fetal |
 Patient History for Fetal Molecular Testing |
|
| 0051266 |
Achondroplasia, Mutation |
Patient History for Molecular Testing |
|
| 0040033 |
Acylcarnitine Quantitative Profile, Plasma |
Patient History for Biochemical Genetics |
|
| 0080137 |
Amino Acids Quantitative, CSF |
Patient History for Biochemical Genetics |
|
| 0080710 |
Amino Acids Quantitative, Plasma |
Patient History for Biochemical Genetics |
|
| 0080044 |
Amino Acids Quantitative, Urine |
Patient History for Biochemical Genetics |
|
| 0080434 |
Alpha Fetoprotein (Maternal Serum Only) |
Patient History for Maternal Serum Testing |
|
| 0051495 |
Alpha Thalassemia, HBA1 & HBA2 Gene Deletions |
Patient History for Hemoglobinopathy/
Thalassemia Testing |
|
| 0051415 |
Ashkenazi Jewish Panel |
Patient History for Molecular Genetics |
|
| 0050578 |
Beta Globin (HBB) Full-Gene Sequencing |
Patient History for Hemoglobinopathy/
Thalassemia Testing |
|
| 0051421 |
Beta Globin Gene Mutations for HbS, HbC, & HbE by PCR |
Patient History for Hemoglobinopathy/
Thalassemia Testing |
|
| 0051422 |
Beta Globin S,C,E, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0050388 |
Beta Globin Sequencing, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051433 |
Bloom Syndrome, BLM Gene 2281del6/ins7 Mutation |
Patient History for Molecular Genetics |
|
| 0051434 |
Bloom Syndrome, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051453 |
Canavan Disease, ASPA Gene Mutations |
Patient History for Molecular Genetics |
|
| 0051454 |
Canavan Disease, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051682 |
Carnitine Deficiency, Primary, Full Gene Sequencing |
Patient History for Primary Carnitine Deficiency Testing |
|
| 0081110 |
Carnitine Panel |
Patient History form Biochemical Genetics |
|
| 0080512 |
Carnitine Transport, Fibroblasts |
Patient History for Biochemical Genetics |
|
| 0097601 |
Chromosome Analysis, Amniotic Fluid |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097605 |
Chromosome Analysis, Bone Marrow |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097688 |
Chromosome Analysis, Breakage Syndrome Analysis |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097610 |
Chromosome Analysis, Chorionic Villus Sampling (CVS) |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097620 |
Chromosome Analysis, Fetal Blood (PUBS) |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0092615 |
Chromosome Analysis, FISH-Interphase
|
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097615 |
Chromosome Analysis, FISH-Metaphase
|
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097630 |
Chromosome Analysis, High Resolution (Prometaphase Study) |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097635 |
Chromosome Analysis, Leukemic Blood |
Patient History for Cytogenetic (Chromosome) Studies |
|
|
|
English |
Español |
| 0090188 |
Chromosome Analysis, Oncology |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097640 |
Chromosome Analysis, Peripheral Blood |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097779 |
Chromosome Analysis, Prenatal FISH |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097645 |
Chromosome Analysis, Products of Conception |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097650 |
Chromosome Analysis, Rule Out Mosaicism |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097677 |
Chromosome Analysis, Sister Chromatid Exchange |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097655 |
Chromosome Analysis, Skin Biopsy |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0097778 |
Chromosome Analysis, Solid Tumor |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0051374 |
Connexin 26 (GJB2), Sequencing |
Patient History for Connexin 26 (GJB2) |
|
| 0051383 |
Connexin 26 (GJB2), 35delG Mutation Detection |
Patient History for Connexin 26 (GJB2) |
|
| 0050098 |
Cystic Fibrosis, 3199del6 Only
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History for Cystic Fibrosis |
|
| 0050756 |
Cystic Fibrosis, Atypical
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History for Cystic Fibrosis |
|
| 0056006 |
Cystic Fibrosis, Cis-Trans
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History for Cystic Fibrosis |
|
| 0051110 |
Cystic Fibrosis, Full Gene Analysis
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History for Cystic Fibrosis |
|
| 0056040 |
Cystic Fibrosis, Mutation Panel |
Patient History for Cystic Fibrosis |
|
| 0050393 |
Cystic Fibrosis, Mutation Panel, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051150 |
Cystic Fibrosis Mutation Panel with Reflex to CFTR Full Gene Analysis |
Patient History for Cystic Fibrosis |
|
| 0081106 |
Cystine Quantitative, Urine |
Patient History for Biochemical Genetics |
|
| 0081105 |
Cystinuria Panel |
Patient History for Biochemical Genetics |
|
| 0051103 |
Cytochrome P450 2C9 Genotyping |
Patient History for Pharmacogenetics |
|
| 0051104 |
Cytochrome P450 2C19 Genotyping |
Patient History for Pharmacogenetics |
|
| 0051232 |
Cytochrome P450 2D6 Genotyping |
Patient History for Pharmacogenetics |
|
| 0051232 |
Factor V Leiden by PCR & Fluorescence Monitoring |
Patient History for Molecular Genetics |
|
| 0051463 |
Familial Dysautonomia, IKBKAP Gene Mutation |
Patient History for Molecular Genetics |
|
| 0051464 |
Familial Dysautonomia, IKBKAP Gene Mutation, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051468 |
Fanconi Anemia Group C, FANCC Gene Mutations |
Patient History for Molecular Genetics |
|
| 0051469 |
Fanconi Anemia Group C, FANCC Gene Mutations, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0082024 |
Fetal Fibronectin |
Patient History for Fetal Fibronectin |
|
| 0040011 |
Fragile X Syndrome, DNA Testing |
Patient History for Molecular Genetics |
|
| 0050543 |
Fragile X Syndrome, DNA Testing, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051175 |
Galactosemia, Panel |
Patient History for Galactosemia |
|
|
|
English |
Español |
| 0051176 |
Galactosemia, DNA Testing |
Patient History for Galactosemia |
|
| 0051270 |
Galactosemia Mutation Panel, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0080125 |
Galactose-1-Phosphate Uridyltransferase |
Patient History for Galactosemia |
|
| 0051438 |
Gaucher Disease, GBA Gene Mutations |
Patient History for Molecular Genetics |
|
| 0051439 |
Gaucher Disease, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0060740 |
Genomic Microarray Analysis for Constitutional Abnormalities |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0060742 |
Genomic Microarray Panel: Constitutional and Comprehensive Coverage |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0060741 |
Genomic Microarray Comprehensive Coverage |
Patient History for Cytogenetic (Chromosome) Studies |
|
| 0055656 |
Hemochromatosis Mutation Detection (C282Y, H63D, & S65C), Hereditary |
Patient History for Molecular Genetics |
|
| 0050610 |
Hemoglobin Evaluation with Reflex to Electrophoresis and/or RBC Solubility |
Patient History for Hemoglobinopathy/
Thalassemia Testing |
|
0051255
|
Hereditary Hemorrhagic Telangiectasia, Fetal, Family Specific Mutation (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History for Fetal Molecular Testing |
|
| Informed Consent HHT Family Specfic Mutation (FSM) |
 |
| 0051212 |
Hereditary Hemorrhagic Telangiectasia Family Specific Mutation (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History for HHT Molecular Genetic Testing
|
|
| Informed Consent HHT Family Specfic Mutation (FSM) |
|
| 0051348 |
Hereditary Hemorrhagic Telangiectasia Deletion & Duplication (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History HHT Molecular Genetic Testing
|
|
| Informed Consent HHT Deletion/Duplication |
|
| 0051381 |
Hereditary Hemorrhagic Telangiectasia Full Gene Sequencing (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History HHT Molecular Genetic Testing
|
|
| Informed Consent HHT Full Gene Analysis (FGA) |
|
| 0051382 |
Hereditary Hemorrhagic Telangiectasia Full Gene Analysis (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439. |
Patient History HHT Molecular Genetic Testing
|
|
| Informed Consent HHT Full Gene Analysis (FGA) |
|
| 0051648 |
HNPCC/Lynch Syndrome, Family Specific Mutation |
Patient History for HNPCC/Lynch Syndrome Testing |
|
| 0080108 |
Maternal Serum Screening, Alpha Fetoprotein, hCG & Estriol |
Patient History for Maternal Serum Testing |
|
| 0080269 |
Maternal Serum Screening, Alpha Fetoprotein, hCG, Estriol, & Inhibin |
Patient History for Maternal Serum Testing |
|
| 0081150 |
Maternal Serum Screening, First Trimester |
Patient History for Maternal Serum Testing |
|
| 0081062 |
Maternal Serum Screening, Integrated Specimen #1 |
Patient History for Maternal Serum Testing |
|
| 0081064 |
Maternal Serum Screening, Integrated Specimen #2 |
Patient History for Maternal Serum Testing |
|
| 0055655 |
Methylenetetrahydrofolate Reductase Mutation Detection (Thermolabile form) (C677T & A1298C) |
Patient History for Molecular Genetics |
|
| 0051650 |
MLH1 Full Gene Analysis |
Patient History for HNPCC/Lynch Syndrome Testing |
|
| 0051448 |
Mucolipidosis IV, MCOLN1 Gene Mutations |
Patient History for Molecular Genetics |
|
| 0051449 |
Mucolipidosis IV, Fetal |
Patient History for Fetal Molecular Testing |
|
|
|
English |
Español |
| 0051654 |
MSH2 Full Gene Analysis
|
Patient History for HNPCC/Lynch Syndrome Testing |
|
| 0051656 |
MSH6 Full Gene Analysis |
Patient History for HNPCC/Lynch Syndrome Testing |
|
| 0051390 |
Multiple Endocrine Neoplasia Type 2 (MEN2), RET Gene Mutations by Sequencing |
Patient History for Multiple Endocrine Neoplasia 2, (MEN2) RET Gene |
|
| 0051492 |
Multiple Endocrine Neoplasia Type 2B (MEN2B), RET Gene M918T and A883F Mutations |
Patient History for Multiple Endocrine Neoplasia 2, (MEN2) RET Gene |
|
| 0051459 |
Niemann-Pick Disease Type A, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051459 |
Niemann-Pick Disease, SMPD1 Gene Mutations, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0099289 |
Organic Acids, Plasma |
Patient History for Biochemical Genetics |
|
| 0098389 |
Organic Acids, Urine |
Patient History for Biochemical Genetics |
|
| 0051308 |
Platelet Antigen Genotyping Panel |
Patient History for Fetal Molecular Testing |
|
| 0056060 |
Prothrombin Nucleotide 20210 G/A Gene Mutation (Factor II) |
Patient History for Molecular Genetics |
|
| 0051614 |
Rett Syndrome (MECP2), Full Gene Analysis |
Patient History for Rett Syndrome (MECP2) Testing |
|
| 0051378 |
Rett Syndrome (MECP2), Full Gene Sequencing |
Patient History for Rett Syndrome (MECP2) Testing |
|
| 0051618 |
Rett Syndrome (MECP2), Deletion and Duplication |
Patient History for Rett Syndrome (MECP2) Testing |
|
| 0050421 |
Rh Genotyping (C,c) |
Patient History for Fetal Molecular Testing |
|
| 0051368 |
Rh Genotyping (D) |
Patient History for Fetal Molecular Testing |
|
| 0050423 |
Rh Genotyping (E,e) |
Patient History for Fetal Molecular Testing |
|
| 0051510 |
SMAD4 (MADH4) Full Gene Sequencing |
Patient History for SMAD4 Testing |
|
| 0051428 |
Tay-Sachs Disease, HEXA Gene Mutations |
Patient History for Molecular Genetics |
|
| 0051429 |
Tay-Sachs, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051508 |
Thanatophoric Dysplasia Type I/II Panel, Fetal |
Patient History for Fetal Molecular Testing |
|
| 0051332 |
UGT1A1 Genotyping for Irinotecan Sensitivity |
Patient History for Pharmacoenetics |
|
| 0051370 |
Warfarin Genotyping |
Patient History for Pharmacogenetics |
|
