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UPMC Presbyterian Hematopathology Testing Service Bone Marrow/Blood/Body Fluid Specimens DELIVER TO: Clinical Flow Cytometry Lab S-763 Scaife Hall, Tel: (412) 624-3746 Fax: (412) 624-6863 Call to notify lab prior to sending
specimens. |
Space for optional
addressograph |
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PATIENT
INFORMATION– Complete all fields.
Attach patient insurance/demographic information. PLEASE PRINT. |
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Last
Name
First Name
M.I. |
Social
Security Number |
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□ Outpatient □ Inpatient – Room # __________ |
Birth
Date |
Sex |
Diagnosis |
ICD
9 Code |
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REPORTING INFORMATION – Complete all fields. |
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Requesting
Physician Name |
Phone
(Including Area code) |
Fax
(Including Area Code) |
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Institution
name |
Phone
(Including Area code) |
Fax
(Including Area Code) |
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Copy
to: Physician name |
Phone
(Including Area code) |
Fax
(Including Area Code) |
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Name of person
filling out form:
Phone #: |
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CLINICAL HISTORY/PERTINENT PHYSICAL FINDINGS): (use back of requisition as needed) |
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Chemotherapy: Last Date: □ Yes □ No Growth Factor: □ Yes □ No |
Other Medications (include names of growth factors): |
Previous Radiation Therapy: □ Yes □ No Date: |
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TYPE OF SPECIMEN □ Peripheral Blood*
□ Fluid
(specify site and type of specimen): ____________________
□ Right Iliac Crest Bone
Marrow* □ Left Iliac Crest Bone
Marrow* *Please send a copy of the
most recent CBC & differential and a peripheral smear. |
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Time & Date specimen obtained: Time & Date specimen sent: |
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BONE MARROW TESTING REQUEST |
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□ Bone Marrow Smears for
Interpretation □ Bone Marrow Biopsy for
Interpretation |
□ Bone Marrow Particle Prep
for Interpretation (yellow top/ACD tube) □ Iron Stain |
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□ Cytochemical Stains (specify): __________________________________________________________________________ |
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FLOW CYTOMETRY TESTING REQUEST□ Evaluation with major concern for: □ Blasts □ Lymphoid Cells □ Other _______________________ |
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□ Immunodeficiency Evaluation (CDC Recommended T
cell subset panel
of: CD3, CD4, CD8, CD19, CD16&56 and CD4:CD8 ratio) |
□ Evaluation of CD4+ cells
only □ Evaluation for PNH |
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□ MOLECULAR ONCOLOGY TESTING MUST complete Molecular Oncology Tests requisition |
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□ CYTOGENETIC ANALYSIS (Classical/FISH) MUST complete |
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Updated