RESEARCH LABORATORY REQUEST FORM
I.
REGISTRATION INFO.
Patient Name: _________________________________________________
LAST NAME
Date of Birth: _______________
FIRST NAME
M
F
Medical Records Number: _______________________________________
SEX:
Requesting Physician: __________________________________________
Diagnosis Code: _____________
Insurance: ____________________________________________________
Register will need a copy of
patient’s insurance card.
II.
STUDY INFO.
STUDY NAME: ______________________________________________________________________________
STUDY I.D. NUMBER: ___________________________________
Collection Date: ____________ Collection Time: ___________  AM  PM
III.
LAB - ORDER AND RECEIVE THE SELECTED IN-HOUSE LABS
____
____
____
____
____
____
____
____
____
____
Basic Metabolic Panel
Comprehensive Metabolic Panel
Electrolyte Panel
Hepatic Function Panel (Liver Panel)
Fasting Lipid Panel
Renal Panel
Cardiac Profile (Total CK & CKMB, reflex Index)
Gamma Glutamyl Transferase (GGT)
Hemoglobin A1C
Apolipoprotein A1s
____
Apolipoprotein B
____
Partial Thromboplastin Time
____
Protime w/INR
____
Hemoglobin and Hematocrit
____
CBC w/o Platelet & Differential
____
CBC w/ Platelet & Differential
____
Urinalysis
____ Other: __________________________________
____ Other: __________________________________
____ Other: __________________________________
DELIVER THIS FORM & ALL LABELS TO RESEARCH BENCH WITH BLOOD
IV.
RESEARCH BENCH
** FOR RESEARCH BENCH USE ONLY**
Time Spun
:
1
2
3
4
5
6
7
8
Serum Cryovials
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
0.5ml 0.25ml QNS
Comments:
8/2012, V4
Generic_LaboratoryRequestForm.doc
Time Frozen
:
Select the appropriate volume for each cryovial
Whole Blood Cryovials
Plasma Cryovials
1 ml
0.5 ml
QNS
0.5ml
0.25ml
QNS
1 ml
0.5 ml
QNS
0.5ml
0.25ml
QNS
1 ml
0.5 ml
QNS
0.5ml
0.25ml
QNS
1 ml
0.5 ml
QNS
0.5ml
0.25ml
QNS
0.5ml
0.25ml
QNS
0.5ml
0.25ml
QNS
0.5ml
0.25ml
QNS
Storage Box #
Buffy Coat
Yes
No
□ Inventory Data Captured
□ Manifest Data Captured
□ Charges Captured
□ Shared File Updated