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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