Request for Platelet Testing - Red Cross Blood



4629150-6668Platelet Laboratory Use Only:Date: ____________Time: _______ Initials: _________Condition: ____________________ Stored: _________Accession#:00Platelet Laboratory Use Only:Date: ____________Time: _______ Initials: _________Condition: ____________________ Stored: _________Accession#:American Red Cross - Platelet Serology LaboratoryMinnesota - Dakota Region, St. Paul, MNPhone:(651) 291-6797 - Local (855) 216-9202 – Toll-FreeFax: (651) 291-3233Web site: Page 2 for instructions, sample types, labeling, and shipping requirementsPatient Information:*Name _______________________________________*DOB ____________*Patient ID/MR# ________________________________________________*Gender _____ male _____ female*Institution _____________________________________________________Department/Address _____________________________________________*City/State/ZIP__________________________________________________Contact Name ________________________Phone_____________________E-Mail ________________________ Fax ___________________________* Required Information Specimen Information:*Collection date ___________________*Specimen type (check one) ____ Serum ____ Plasma (anticoagulant type) ________*Physician ________________________Reports: ____ E-mail ____Fax* Required Information Diagnostic Platelet Tests:____ Platelet Antibody Identification ____ HPA-1a (PlA1) Antigen typing (Phenotyping)Clinical Conditions: ____ Alloimmune Neonatal Thrombocytopenia (NAIT)____ Autoimmune Thrombocytopenia (AITP)____ Post Transfusion Purpura (PTP)____ Platelet Transfusion Refractoriness____ Drug Induced Thrombocytopenia____ Other: __________________________________Relevant Comments: _________________________________________________________________________________________________________________Platelet Crossmatch:____ Platelet Crossmatch (Order platelet products below) ____ Platelet Crossmatch Incompatibility Screen ______________ (Specify ABO types)Patient Information____________ Patient’s ABO/Rh TypePlatelet Product Requirements____________ Number of Platelet Products Requested____________ Date Needed____________ ABO/Rh Type Requested (Option #1) ____________ ABO/Rh Type Requested (Option #2) ____________ ABO/Rh Type Requested (Option #3) ____________ ABO/Rh Type Requested (Option #4)Special Requirements____ CMV Negative____ Other: __________________________________Instructions for Submission of SamplesRefer to the table below for specimen and shipping requirements. Specimens must be shipped following federal and local requirements for shipping biological substances category B.Label the specimen vial(s) with the patient’s name, a second identifier (date of birth or medical record number) and the collection plete Page 1 of the request form and include it with the sample vial(s).Send samples Monday-Thursday to ensure weekday delivery.Refer to the table below for shipping requirements. Specimens must be shipped following federal and local requirements for shipping biological substances category B.Shipping Address:Business Hours:8:00 AM to 4:30 PM Monday - FridayPlatelet Serology LaboratoryPhone:(651) 291-6797 or (855) 216-9202American Red CrossFax:(651) 291-3233100 South Robert StreetSaint Paul, MN 55107Web site: RequirementsShippingPlatelet Crossmatch Platelet Crossmatch Incompatibility Screen3-4 mL plasma only (EDTA, ACD, CPD, or CPDA-1).Separate plasma from red cells.Refrigerate or freeze specimen as soon as possible.Samples can be tested up to 14 days after collection.Send on wet ice/cold pack within 48 hours after collection.Send on dry ice greater than 48 hours after collection.Platelet Antibody Identification (Indirect)1 mL serum only.Separate serum from red cells. Refrigerate for no longer than 48 hours after collection.Freeze specimen if greater than 48 hours after collection.Send on wet ice/cold pack within 48 hours after collection.Send on dry ice greater than 48 hours after collection.HPA-1a (PlA1) Antigen Typing6-10 mL EDTA whole blood (DO NOT SEPARATE).Store whole blood at room temperature (DO NOT REFRIGERATE OR FREEZE).Specimen must be tested within 24 hours following collection.Needs to arrive at our lab less than 24 hours after collection.Send at room temperatureSend samples Monday-Thursday to ensure weekday delivery ................
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