Name *

DOB *

- Month - Day Year

Sex *

Male Female

Diagnosis Code *

Date of Collection *

- Month - Day Year

Time of Collection *

: Hour Minutes

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

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 *

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)