Res Lab#
_____________
Date Rec’d
_____________
National Program for Hemophilia Mutation Testing
Department of Pathology and Molecular Medicine, Richardson Laboratory, Room 201
Queen’s University, Kingston, Ontario K7L 3N6
E-Mail: nphmt@clinlabs.path.queensu.ca
Hemophilia A and B Genotype Testing – Requisition
Male 
Patient Name ________________________________
Female 
(Surname, First Name)
DOB
____/____/____
YY
MM
Unique Identifier___________________
DD
eg. Health card # , Hospital #
Referring Clinic _____________________
Test Requested
Hemophilia A 
Coagulation Factor Level
Inhibitor
Yes 
No 
Report to _________________________
Hemophilia B 
Factor VIII ________ U/mL
Factor IX ________U/mL
Inhibitor Titre _______________ B.U.
Has intron 22 inversion testing been done?
Yes 
No 
Information Requested






New case of severe Hemophilia A or B
Documented family history of indicated disease
Carrier status
Prenatal diagnosis
Sporadic / isolated case of Hemophilia A or B
Unusual case for research
Have samples from this family been sent to this lab before?
Yes 
No 
If Yes, specify ___________________________________________________________
Relationship to this patient _________________________________________________
Sample Requirements: EDTA (lavender top)
OR ACD (yellow top)
OR DNA
Ship to the above address (attn: Jayne Leggo)
Sample Rec’d _________________