Place Patient Label Here
VEGF-D serum concentration
SAMPLE SUBMISSION FORM
(Place additional labels on
the back of requisition)
TTDSL#
Clinical Laboratory
Translational Trials Development and Support Laboratories (TTDSL)
Translational Cores, Division of Experimental Hematology and Cancer Biology
(internal use only)
Cincinnati Children’s Hospital Medical Center
240 Albert Sabin Way, S11.400, MLC 7013
Cincinnati, OH 45229
Date Received:
(internal use only)
Cerner Entry □ Tech ID: __________
Center Verify □ Tech ID: __________
email: ttdsl@cchmc.org
Phone: 513-636-5998
Fax: 513-636-1446
1. Patient/ Physician Information
Specimen Collection date:
/
Specimen collection time:
Patient Name: (Last, First, Mid. Int.)
/
Hospital MR #
Sex:
F
Referring Institution:
Name of the authorized contact person:
Referring Physician:
Phone:
Date of Birth:
M
/
/
Physician Fax #:
AUTHORIZED SIGNATURE: (required)
Diagnosis: ____________________
(Please check all that apply)
□ Patient has diagnosis of Tuberous sclerosis Complex (TSC)□ Patient does not have TSC
□ TSC status unknown
□ Patient has diagnosis of Lymphangioleiomyomatosis (LAM) □ Patient does not have LAM
□ LAM status unknown
□ Patient has a chest CT with cystic changes
□ Patient has history of pneumothorax
□ Patient does not have history of pneumothorax
□ List other diagnosis if known: _____________________
2. Specimen Type
Cincinnati LOCAL SAMPLE: SHIPPED SAMPLE:
□ ≥ 3 ml whole Blood in serum
□ ≥ 1 ml serum isolated from blood collected in serum separator tube (SST)
separator tube (SST)
Note: must be received by
Lab within 2 hrs of draw
(see page 2 option (B) for instructions)
Check one:
□ Fresh (shipped at ambient temperature)
□ Frozen (shipped on dry ice)
Note: Store serum at ambient temperature or  -20°C. Do NOT store at 4°C
3. Test requested  Determination of serum concentrations of Vascular Endothelial Growth Factor D (VEGF-D)
Special handling: □ This sample is a clinical trial specimen and therefore, the following modifications are requested (indicate specific request
in this box).
4. Reporting instructions
Submit Original Report to:
Submit Report Copies to:
5. Billing Information
□ Patient Billing
□ Referring Institution (Submit Invoices to) :
□ Check Enclosed □ Credit Card (Visa/MC, Amex)
Credit Card Number: __________________________
Card Holder Name: ___________________________
Expiration Date: ______________________________
Signature: ___________________________________
□ Commercial Insurance/Policy Holder Information
Name: ____________________________________ Gender: _____ Date Of Birth: _____/_____/_____
Authorization Number: _________________________ Insurance Name: _____________________________________________
Insurance Address:________________________________________________________________________________________
City/State/Zip: ___________________________________________________________________________________________
Insurance ID Number: __________________________ Group Number: ______________________________________________
Insurance Phone Number: __________________________________________________________________________________
6. Specimen handling after completion of testing-please check all that apply
□ Left over specimens may be used for research purposes
□ Patient is willing to be contacted for possible participation in clinical trials and research studies
□ Patient followed in a LAM Foundation Clinic
□ Patient participated/participating in a LAM trial: Specify: ______________
□ Patient is consented to the following research protocol:______________________(list protocol ID). Leftover specimens can be used for research purposes.
□ Patient is willing to get contacted for participation in clinical trials in case of a positive test result.
Procedures for VEGF-D specimen collection, processing and shipping to CCHMC TTDSL Clinical Lab
Please notify lab of intent to submit a specimen prior to send out:
TTDSL@cchmc.org,
Phone: 513-636-5998
(A) Sample type: whole Blood in SST (for on-site collection in Cincinnati)
(1) Collect approximately ≥ 3 ml of whole blood in a serum separator tube (SST) by venipuncture
(2) Immediately invert the sample 8-10 times.
(3) Transport at ambient temperature to CCHMC TTDSL for receipt within 2 hrs of draw.
(B) Sample type: serum (for shipment to Cincinnati)
(1) Collect approximately ≥ 3 ml of whole blood in a serum separator tube (SST)
(2) Immediately invert the sample 8-10 times.
(3) Allow the sample to sit upright for at least 30 min at room temperature for proper clotting. Proceed to next step
within 2 hrs of collection.
(4) Centrifuge for ~15 min at 1250 g (relative centrifugal force (RCF)).
(5) Transfer the layer of serum above the separator gel from the tube immediately into a sealable, leak proof
container (cryovial(s) or polypropylene 15 ml Falcon tube). Label container with at least 2 unique patient
identifiers matching the information on request form. Seal the container.
(6) If sample is being shipped the same day as the sample collection:
 Store specimen at ambient temperature until pickup. (Do NOT store at 4°C)
 Ship sample ambient via Fedex overnight in an insulated container (such as Styrofoam).
 If overnight shipment is not available, send specimen on dry ice. Ensure that packages are shipped in
compliance with all applicable Federal/State regulations.
(7) If the sample cannot be shipped on the day of collection:
 Store serum at  -20°C until scheduled shipment.
 Send specimen on dry ice. Ensure that packages are shipped in compliance with all applicable Federal/State
regulations.
(8) Ship to:
Translational Trials Development and Support Laboratory (TTDSL)
Cincinnati Children’s Hospital Medical Center
240 Albert Sabin Way,
S11.400, MLC 7013
Cincinnati, OH 45229
Contact phone: 513-636-5998
(9) Notify CCHMC TTDSL of the shipment (TTDSL@cchmc.org or 513-636-5998) and provide the tracking
number.
Shipped via:
 Fedex  Other_______________ Tracking Number:
___________________
TTDSL is open M-F 8 am - 4 pm EST except during holidays.
**BOTH PAGES OF REQUISITION MUST BE COMPLETED. INCOMPLETE FORMS MAY RESULT IN THE
COMPROMISE OF THE SPECIMEN’S INTEGRITY WHILE THE MISSING INFORMATION IS BEING OBTAINED**