Tissue Typing Requisition - Calgary Laboratory Services printable pdf download

TISSUE TYPING REQUISITION

Shaded areas must be completed

 ACH

 RGH

PERSONAL

REGIONAL HEALTH

 FMC

 PLC

HEALTH

RECORD NUMBER

___ ___ ___ ___ ___ ___ ___ ___ ___

NUMBER (PHN)

 SHC

 OTHER ______________

PATIENT LAST NAME

FULL FIRST NAME

MIDDLE NAME

CLINIC / UNIT: ________________________________________________________

PATIENT ADDRESS

CITY, PROVINCE

POSTAL CODE

ORDERING PHYSICIAN

CHART NUMBER

GENDER

DATE OF BIRTH

PATIENT PHONE NUMBER

(Last Name)

(Full First Name)

__ __ __ __ / __ __ / __ __

(__ __ __) __ __ __

__ __ __ __

ATTENDING PHYSICIAN:

Y Y Y Y

M M

D D

PRIORITY:

SHIPPING INFORMATION:

(Last Name)

(Full First Name)

Diagnostic & Scientific Centre (DSC)

ROUTINE

STAT

COPY TO:

Loading Dock

TIMED

ASAP

3520 Research Way NW

1) ______________________ _______________________ ____________________

REQUISITIONED BY:

Calgary, Alberta T2L 2K5

Last Name

Full First Name

Office Address/Location

Tel: (403) 770-3652

Fax: (403) 770-3743

2) ______________________ _______________________ ____________________

Last Name

Full First Name

Office Address/Location

PATIENT INFORMATION & TEST REQUEST MUST BE COMPLETED TO ENSURE ACCURATE TESTING & INTERPRETATION

TEST REQUEST

Specimen Requirements

HLA TYPING

ABC

HLA ABC TYPING

2 x 10 mL ACD-A tube

HLA DR

HLA DR-DQ TYPING

2 x 10 mL ACD-A tube

ABCDR

HLA ABC-DR-DQ TYPING

2 x 10 mL ACD-A tube

CROSSMATCH

DXMR

CROSSMATCH Recipient

2 x 5 mL plain clotted tube

AUTOCROSSMATCH Recipient

AUXM

4 x 10 mL ACD-A tube

DXMD

CROSSMATCH Donor

6 x 10 mL ACD-A tube

HLA ANTIBODY INVESTIGATION

BHLA ABS

Post Renal Biopsy HLA Antibody Investigation

2 x 5 mL plain clotted tube

HLA LMX

Luminex Flow HLA Antibody Investigation

2 x 5 mL plain clotted tube

Transfusion Refractory Bone Marrow Recipient

PHLA ABS

2 x 5 mL plain clotted tube

DISEASE ASSOCIATION & PHARMACOGENETICS *see below

B27 Ankylosing Spondylitis

ABC

HLA ABC TYPING

B5701 Abacavir HS

B1502 SJS/TEN (Asian Patients)

2 x 10 mL ACD-A tube

A3101 SJS/TEN (Caucasian Patients)

B51 Behcet Disease

A29 Birdshot Retinochoroidopathy (Uveitis)

DQ2/DQ8 Celiac

HLA DR

HLA DR-DQ TYPING

2 x 10 mL ACD-A tube

DR15/DQB1*06:02 Narcolepsy

PATIENT INFORMATION

Bone Marrow Transplant

Solid Organ Transplant

Disease Association *see above

Autologous

Renal Recipient

Other:

Allogeneic Recipient

Renal Related Donor

___________________________________

Allogeneic Related Donor

Relationship ________________________

Ethnicity:

Renal Unrelated Donor

Allogeneic Unrelated Donor (MUD)

___________________________________

Relationship ________________________

Diagnosis:

COLLECTED BY:

FOR LABORATORY USE ONLY

ACCESSION NUMBER

DATE COLLECTED

TIME COLLECTED

Laboratory Information Centre: 403-770-3600

CLS Form# REQ9054TT

20140630

Tissue Typing Requisition - Calgary Laboratory Services

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