Name
*
DOB
*
-
-
Sex
*
Male
Female
Diagnosis Code
*
Date of Collection
*
-
Month
-
Day
Year
Time of Collection
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
Accession #
*
Inpatient Enter Admit Date
*
-
Month
-
Day
Year
Place of Service Specimen was Obtained
*
Outpatient
ASC
Office
H #
*
Referring Institution
*
Specimen Type
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Referring Physician Signature
*
Date
*
-
Month
-
Day
Year
AVAILABLE TESTING
ACCEPTABLE SPECIMENS
Available Testing
*
Flow Cytometry Immunophenotyping (Leukemia/Lymphoma)
Hematopathology Consult
CD34+ Stem Cell Enumeration
T cell Lymph Subset Panel (CD3, CD4, CD8, Ratio)
Immune Deficiency Panel
Aquired Immune Deficiency Panel
Rituximab Therapy Evaluation Panel
Acceptable Specimens
*
Bone Marrow (Sodium Heparin – green tops) (EDTA – purple tops)
Peripheral Blood (Sodium Heparin – green tops) (EDTA – purple tops)
Body Fluids (Sterile container or Sodium Heparin Tubes)
Fresh Tissue (Kept Cold – NOT FROZEN) (Kept Moist with Saline Gauze or in RPMI Fluid)
Special Instructions
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