PHRI CV Research Laboratory Request Form



I.REGISTRATION INFO.Patient Name: _________________________________________________Date of Birth: _______________LAST NAMEFIRST NAMEMedical Records Number: _______________________________________SEX: ? M? FRequesting Physician: __________________________________________Diagnosis Code: _____________Insurance: ____________________________________________________Register will need a copy of patient’s insurance card.II.STUDY INFO.STUDY NAME: ______________________________________________________________________________STUDY I.D. NUMBER: ___________________________________Collection Date: ____________ Collection Time: ___________ ? AM ? PMIII.LAB - ORDER AND RECEIVE THE SELECTED IN-HOUSE LABS____Basic Metabolic Panel____Comprehensive Metabolic Panel____Electrolyte Panel____Hepatic Function Panel (Liver Panel)____Fasting Lipid Panel____Apolipoprotein B____ Partial Thromboplastin Time____ Protime w/INR____ Hemoglobin and Hematocrit____ CBC w/o Platelet & Differential____Renal Panel____Cardiac Profile (Total CK & CKMB, reflex Index)____Gamma Glutamyl Transferase (GGT)____Hemoglobin A1C____Apolipoprotein A1s____CBC w/ Platelet & Differential____Urinalysis____ Other: ______________________________________ Other: ______________________________________ Other: __________________________________DELIVER THIS FORM & ALL LABELS TO RESEARCH BENCH WITH BLOODIV.RESEARCH BENCH ** FOR RESEARCH BENCH USE ONLY**Time SpunTime FrozenStorage Box #::Select the appropriate volume for each cryovial Serum CryovialsWhole Blood CryovialsPlasma CryovialsBuffy Coat10.5ml0.25mlQNS1 ml0.5 mlQNS0.5ml0.25mlQNSYes20.5ml0.25mlQNS1 ml0.5 mlQNS0.5ml0.25mlQNSNo30.5ml0.25mlQNS1 ml0.5 mlQNS0.5ml0.25mlQNS40.5ml0.25mlQNS1 ml0.5 mlQNS0.5ml0.25mlQNS□ Inventory Data Captured50.5ml0.25mlQNS0.5ml0.25mlQNS□ Manifest Data Captured60.5ml0.25mlQNS0.5ml0.25mlQNS□ Charges Captured70.5ml0.25mlQNS0.5ml0.25mlQNS□ Shared File Updated80.5ml0.25mlQNSComments: ................
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