Northern England Haemato-Oncology Diagnostic Service Hard Copy Request Form

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Northern England Haemato-Oncology Diagnostic Service NEHODS
NEHODS, Blood Sciences Reception, Level 3, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP
0191 282 5028
tnu-tr.nehods@nhs.net
SAMPLE DETAILS
SPECIMENS
‘Originating’ LABORATORY NUMBER
PATIENT DETAILS
Surname:
Forename:
If very Urgent, phone 0191 282 5028
Peripheral blood
NHS Number:
Bone marrow aspirate
Known or suspected Biohazard?
Postcode:
SPECIFIC TESTS REQUIRED
Site:
Please label appropriately
Date of Birth:
Bone marrow trephine
Morphology
Site:
Iron Stain
Referring Hospital:
Lymph Node
Requested by:
Flow cytometry
Site:
Ward:
ALP
LP
Hold
Date and time requested:
CSF
Referring Consultant:
Cytogenetics
Other Specimens
Molecular
Contact Details:
Investigational pathway:
CLINICAL DETAILS
FBC:
Hb:
Acute Leukaemia
Suspected/known diagnosis:
Previous NEHODS Sample: Yes
No
MCV:
Cytopenia
WCC:
Lymphoma staging marrow:
Yes
No
Plt:
Myeloproliferative
Neut:
Lymphoma
Lym:
Relevant Clinical History:
(including recent chemo/radiotherapy & G-CSF treatment):
Blast:
Myeloma
Other
Sample taken by:
Date and time:
dd/mm/yyyy hh:mm
Consent (this must be completed)
This patient consents to the storage of sample(s), including any surplus cells or tissue after diagnosis,
for medical research, teaching, audit and quality control.
Yes
No
Confirmed by (signature)
PRINT NAME:
For Lab Use Only
Slide File Number
Lab Number
MARROW
B/
TREPHINE
B/
IMMUNOPHENOTYPING / CYTOCHEMISTRY / DNA PLOIDY
NEHODS HaemoSys Hard Copy Request Form v4

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