REFERRING CLIENT/COLLECTION CENTER
VANDERBILT
Nashville:
(VPLS)VPLS CLIENT ACCOUNT
PA1HOLOGY LABORATORY SERVICES
(615) 936-0510
Continental U.S.:
•
(800)551 -5227
BILL TO:
SEND SPECIMEN(S) TO:
Nurse/Amb=VUH-VPLS
Client Account
4607 The Vanderbilt Clinic
1301 Medical Center Drive
Patient (Billing information must be attached.)
Nashville TN 37232-5310
PATIENT NAME (LAST)
REFERRING PHYSICIAN
(M.L)
(FIRST)
I I
I
o
SEX
FEMALE
0MALE
DATE COLLECTED
I
I -I
SERUM
0
I-I
DATE OF BIRTH
I
I
I-I
I
URINE
3G
(CLIENT)
REQUEST #
SAMPLE ID
B~I
0
I
' -_ _ _ _ _ _ _ _-1
TIME COLLECTED
PLASMA 0
FOR LAB USE ONLY
3G MR #
PATIENT ID NUMBER
1- I
PHONE NUMBER
I
I
3G
I
'-_ _ _ _ _ _ _-!(REFERENCE)
URINE TOTAL VOLUME
OTHER
NOTE: Complete Patient Billing Information (FACE SHEET) must be sent with sample if direct billing is desired.
ORDERING PHYSICIAN:,____________ NPI #:_ _ _ _ _ _ _ _ _ _ __
REFERRING LABORATORY: _ _ _ _ _ _ _ _ _ _ PHONE:
CONTACT PERSON:
FAX: _ _ _ _ _ _ _ _ _ _ __
DIAGNOSIS:
ICD CODE:
PLATELET STUDIES:
PAG
_RAG
MATERNAUFETAL TESTING
PLATELET AGGREGATION
FCF
RISTOCETIN INDUCED
PLATELET AGGREGATION
Testing must be scheduled with Vanderbilt Esoteric
Coagulation Laboratory. Patient should not take over the
counter medications for 10 days prior to testing. Patient must
present to Vanderbilt between 8:00 and 8:30 AM on the day of
testing. Patient should be fasting. Vanderbilt Esoteric
Coagulation: 615- 875-5633
~QA~9~TION TESTING
_AT3
_001
_DVT
_LUP
_ PCA
_SAT
PT2
F5
FVL
F7
F8
81N
F9
91N
F10
F11
F12
F13
_CAC
PS
_LAS
_IT
_RW
_APA
Anti-thrombin III Activity
D-Dimer for DIC
D-Dimer for PE/DVT
Lupus Anticoagulant Profile
Protein C Antigen
Protein S Antigen Total
(pROTH ROMBI N)GENOTYPE
FACTOR V ACTIVITY
FACTOR V LEI DEN COAG
FACTOR VII ACTIVITY
FACTOR VIII ACTIVITY
FACTOR VIII INHIBITOR
FACTOR IX ACTIVITY
FACTOR IX INHIBITOR
FACTOR X ACTIVITY
FACTOR XI ACTIVITY
FACTOR XII ACTIVITY
FACTOR XIII SCREEN
PROTEIN C ACTIVITY
PROTEIN S ACTIVITY
Sta-Clot LA (LUPUS ANTICOAG)
THROMBIN TIME
DILUTE RUSSELL VIPER
ANTI CARDIOLIPIN AB
LBC
FETAL CELL ASSAY - FLOW CYTOMETRY
LAMELLAR BODY COUNT I FETAL LUNG MATURITY
(Gestational Age =_ _ __ weeks)
FFN
FETAL FIBRONECTIN
TOX TESTING
FK5
FK-506 (TACROLIMUS) LEVEL
SIR
SIROLIMUS (RAPAMYCIN. RAPAMUNE) LEVEL
CYO
CYCLOSPORINE LEVEL
AMINO ACID TESTING
AA
PLASMA AMINO ACIDS
CSA
CSF AMINO ACIDS
AAU
URINE AMINO ACIDS
OTHER TESTS
Please List Test(s) Requested:
For more information or aSSistance,
please call VPLS at (800)-551-5227,
or visit us on-line at www.labVU.com
e Vanderbilt University Medical Center
FORM NO. 60-002-664 (REV 07/10)
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