Get Fanc Sample Submission Form - Cincinnati Children's Hospital ... - Cincinnatichildrens

This guide provides clear and comprehensive instructions for completing the FANC Sample Submission Form at Cincinnati Children's Hospital. By following these steps, you can ensure accurate submission and processing of specimens for Fanconi Anemia analysis.

Follow the steps to accurately complete the form

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Provide patient and physician information in Section 1. Include the specimen collection date, time, patient name, hospital medical record number, sex, referring institution, and the authorized contact person's name. Ensure that the authorized signature is provided.
3. In Section 2, specify the reporting instructions. Indicate where to submit the original report and any copies, and include an email address for interim status reports.
4. For Section 3, indicate the specimen type by checking the appropriate boxes. Options include blood, skin biopsy, EBV transformed lymphoblastic cell line, fibroblast culture, or other types. Also, specify if the specimen is fresh or frozen.
5. Section 4 asks for handling requests. Choose whether to analyze the sample according to standard protocol or indicate any specific requests in the comments section.
6. In Section 5, provide billing information, including the name, phone number, email address, and credit card details if applicable.
7. In Section 6, you will be asked about specimen handling after testing completion. Check the relevant boxes if applicable and ensure to discuss consent with the patient for sample storage.
8. After completing all sections, review the information for accuracy. Save changes, then download, print, or share the completed form as necessary.

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