PLATELET SUPPORT AND MISCELLANEOUS TEST REQUISITION
OneBlood Laboratories
CASE #
3000 W. Cypress Creek Road, Fort Lauderdale, FL
8669 Commodity Circle, Orlando, FL 32819
Ref Lab (407) 226-3824; FAX (407) 226-3830
33309
Ref Lab (954) 777-2677; FAX (954) 970-3286
1731 Riggins Road, Tallahassee, FL 32308
CPL (954) 777-2657; FAX (954) 970-3374
Lab (850) 431-5264; FAX (850) 431-6023
10100 Dr Martin Luther King Jr St N, St. Petersburg,
3451 Northlake Blvd., Lake Park, FL 33403
FL 33716
Ref Lab (561) 469-5168; FAX (561) 472-3925
Ref Lab (727) 568-2126; FAX (727) 568-1168
Send All Requests and Samples to Your Local Reference Laboratory
HOSPITAL/FACILITY INFORMATION
Hospital/Facility Name and Address:
Phone #:
Requesting physician:
Contact person:
Fax:
PATIENT INFORMATION
DONOR INFORMATION
Patient Name:
If Enclosed sample is from a Donor:
Donor’s Name:
MR #:
Donor’s MR# or address:
DOB:
Donor’s DOB:
Date collected:
Time collected:
Ethnic group:
Sex:
M
Date collected:
Time collected:
Relationship of Donor to Recipient:
F
CLINICAL INFORMATION
WBC:
Platelet Count:
Check All That Apply:
ABO:
Diagnosis:
Candidate for BMT(related/unrelated)
PLATELET TRANSFUSION SUPPORT
CODE
Previous Bone Marrow Transplant
History of refractoriness
MISCELLANEOUS TESTING
CODE
HLA – A,B Typing for Transfusion
51304
HLA Typing, Transplant support Related: ABC
DR/DQ
HLA Antibody Identification
51167
HPA Antigen Typing
51105
Platelet Crossmatch
51005
FNAIT Assessment: Please complete below
51104
Platelet Antibody Screen
51095
Mother’s Name:
MR#
51238
DOB:
# of HLA Matched Units Requested:
Father’s Name:
# of Platelet Crossmatched Units Requested:
MR#:

Platelet ABO specific requested. Type:
Heparin Induced Thrombocytopenia Antibody (HIT)
51261

Date(s) needed:
Platelet Autoantibodies (Platelet count must be included)
51106
STAT
ASAP
Today
DOB:
Other: _________________________
FOR ONEBLOOD LABORATORY USE ONLY
Sample Description :
Red Top
 Yellow (ACD-A)
 Serum/ Frozen
 Purple/EDTA
 Sample Acceptable Sample Unacceptable (describe)__________________________________________________________
 STAT Charges
 Shipping Charges
Document
Form-70
Version
#4
Page 1 of 2
PLATELET SUPPORT AND MISCELLANEOUS TEST REQUISITION
INSTRUCTIONS AND INFORMATION
SAMPLE REQUIREMENTS
(Fresh samples)
SHIPPING
REQUIREMENTS
HLA A,B Typing (for HLA
matched platelets)
1 EDTA tube for patients older than 10 years and
with a normal CBC, 6 – 10 ml
Room Temperature
3-4 days
Contact lab for patients <10 years or with abnormal CBC
HLA Antibody
Identification
2 Plain Red Top tubes, 6 - 10 ml
Refrigerated
48 hours*
Freeze serum if not delivered within 48 hours
Platelet Crossmatch
1 Plain Red Top tube or 1 EDTA tube, 6 – 10 ml
Room Temperature
Frozen serum
24 hours
48 hours
TAT depends on availability of required platelet products.
Platelet Antibody Screen
1 Plain Red Top 6 - 10 ml tube, or 1 EDTA 6or
10ml tube, or 1 Yellow top ACD-A 10 ml tube
Refrigerated
48 hours*
Freeze serum sample if not delivered within 24 hours, or if
delivered on Friday-Sunday
HPA Antigen Typing
1 EDTA tube, 6 – 10 ml
Room Temperature
48 hours
FNAIT Assessment
1 Plain Red Top tube and 1 EDTA tube on each
parent. Sample on Mother is required; sample
on Father is optional
Refrigerated
48 hours
TEST
EXPECTED TURN
AROUND TIME (TAT)
COMMENTS
Do not draw Neonate
Freeze serum sample if not delivered within 24 hours, or if
delivered on Friday-Sunday
*Samples received on Friday will be resulted the following Monday
Tests That Will Be Referred to Another Qualified Laboratory -- Total TAT Is Dependent on That Lab's TAT
HLA A,B,C/DR DQ (for
transplant support)
2 yellow top ACD-A 10 ml tubes
Platelet Autoantibodies
Yellow top ACD-A 10 ml tubes
See comments for number
Refrigerated
If Platelet Count is:
>100,000 - Draw 10 ml ACD-A whole blood
<100,000 - Draw 40 ml ACD-A whole blood
<20,000 Call lab before collection
Heparin Induced
Thrombocytopenia (HIT)
1 Plain Red Top 6 - 10 ml tube or serum
Refrigerated
Freeze serum sample if not delivered within 24 hours
SPECIAL INSTRUCTIONS:
Blood samples must not be drawn from an IV line.
Room Temperature
To be accepted, all test tubes must be labeled correctly with FULL NAME of patient, Identifying Number, and Date & Time of Collection.
Test tubes should be filled with no less than 5ml of blood (or 3ml of separated serum).
Document
Form-70
Version
#4
Page 2 of 2