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Clinical pharmacogenetic laboratory request form

CLINICAL PHARMACOGENETIC LABORATORY REQUEST FORM
Information about Diet
Patient's Habits
1. THERAPEUTIC DRUG MONITORING (TDM)
Number Name of Molecule
Expected Number of Days to Achieve
Therapeautic Range
Steady State (Css)
1. Alprazolam
2. Amisulpiride
3. Amitriptyline+Nortriptyline
4. Aripiprazole
Dehidroaripiprazole
5. Bupropion(under investigation)
6. Carbamazepine+
10,11-epoxide metabolite
7. Chlorpromazine
8. Citalopram
9. Clomipramine +
Norclomipramine
10. Clonazepam
11. Clozapine + Norclozapine
12. Diazepam +
N-desmethyldiazepam
13. Donapezil
14. Duloxetine HCL
15. Escitalopram
16. Fluoxetine +
Norfluoxetine
17. Flupentixol
18. Fluvoxamine
19. Gabapentine
20. Haloperidol
21. Lamotrigine
22. Levetiracetam
23. Lorazepam
24. Maprotiline
25. Memantine
26. Metylphenidate
27. Mianserine
28. Mirtazapine
29. Moclobemide
30. Naltrexone
31. Olanzapine
32. Opipramol
33. Paliperidone
34. Paroxetine
35. Pimozide
36. Pregabaline
37. Quetiapine
38. Reboxetine
39. Risperidone +
9-OHrisperidone
40. Rivastigmine
41. Sertindole
42. Sertraline
Desmethylsertaline
43. Sulpiride
44. Tianeptine (Under investigation)
45. Topiramate
46. Trazadone HCL
47. Trifluoperazine
48. Venlafaxine + O- Desmethylvenlafaxine
49. Ziprasidone
50. Zuclopenthixol
2. GENETIC PROFILE (PSYCHOTROPIC PANEL)
□ CYP2C9 CYP2D6 □ CYP2C19 CYP1A2
When Obtaining a Genetic Sample:
1) Samples must be contained in hemogram tubes (with purple caps.) 2) For administration of this test, the patient's appetite or use of any other medication is considered necessary. When Obtaining a TDM Sample
For Doctors:
For Technicians:
1) For measurement of the lowest concentration, blood must be 1) Samples should be placed into tubes that contain sodium obtained from the patient right before the last dose of medication, usually 4 days after the beginning of administration. 2) The volume of the sample must be at least 1.5-2 mL. 2) One blood sample is enough for a patient who takes more 3) After the blood sample is obtained at room temperature, it than one kind of medication at the same time. On the other should be centrifuged at 4000 rpm for 15 minutes to seperate the hand, if the medication is administered within seperate intervals, plasma. The seperated plasma should be placed into a dry and seperate blood samples must be obtained from the patient for 4) The seperated plasma should arrive to the laboratory inside a 3) When a TDM report is requested for any type of medication administered to the patient, then a seperate steady-state is done 5) The sample should be given to the NPISTANBUL Neuropsychiatry Hospital Biochemical Laboratory or the Clinical 4) When a toxicity evaluation is requested, a seperate blood sample must be obtained after the steady-state according to the Signature of Requesting Doctor: .

Source: http://www.npistanbul.com/v3/documents/pharmacogenetics_req_form_082010.pdf

minrec.org

yabicoja = unknown, MM 1, 90 (1877). YAG = synthetic gem garnet Y3Al2[AlO4]3, Chudoba EIV, 105 (1974). YAGaG or YAGG = synthetic garnet Ga3Al2[GaO4]3, Bukanov 364 (2006). yagawaralite = yugawaralite, Strunz & Nickel 867 (2001). yagilita = libethenite ?, Domeyko II, 259 (1897). yagite = yagiite, MM 39, 931 (1974). yahalom = massive quartz ± red hematite ± brown goethite, Bukanov 408 (2006). y

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Patient Name: ___________________________________________ DOB: ___________ Appt. Date: __________ Appt. Time: __________Patient Phone: _________________ Referring Physician: ______________________________ SPECIAL REPORTING INSTRUCTIONS:J E R E M Y N . W I E R S I G M . D . , P. A . Addl. Referring Physicians: _______________________________________________________❑ Films with Report to Offic

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