INSERT FORM - Regina Qu'Appelle Health Region
Regina General Hospital
1440 14th Avenue
Regina, SK. S4P 0W5
Tel # (306) 766-4472
|Name: |
|PHN: |
|Date of Birth: |
|Doctor: |
|Date and Time of Collection: By: |
Testing Required: Hypercoagulation or Bleeding Disorder or Lupus
Factor V Leiden
PT Mutant Gene
Please Check Applicable:
|Clinical History-Hypercoag |Clinical History-Bleeding |Family History Follow-up |
|Family Hx of Factor V Leiden |Mennorrhagia |Name |
|Family Hx of PT Mut gene |Nosebleeds |Relationship |
|DVT |Easy Bruising |Diagnosis of affected relative |
|DVT during pregnancy |Family Hx of von Willebrands | |
|Pulmonary embolism |Family Hx of Hemophilia | |
|Recurrent embolism | |Follow up letter attached: Yes ( |
|Stroke | | No ( |
|Other |Other | |
Anticoagulant Therapy: Coumadin Other: ____________________
Heparin
None
Laboratory Results:
|PT | |
|INR | |
|APTT | |
**Specimen Required:**
• Hypercoagulation - 4 separate 1 ml aliquots of double spun sodium citrate plasma–dry ice
- 2 separate 1 ml aliquots of serum – dry ice
-1 EDTA for gene studies - whole blood at room temperature
• Bleeding Disorders - 3 separate 1 ml aliquots of double spun sodium citrate plasma–dry ice
- ** 1 EDTA for Blood Grouping **
- NO SERUM Required
• Lupus Workup - 3 separate 1 ml aliquots of double spun sodium citrate plasma – dry ice
- 2 separate 1 ml aliquots of serum - dry ice
- NO EDTA Required
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