Full Thrombophilia Panel, DNA Assay
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Full Thrombophilia Panel, DNA Assay | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
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Test ID :
LAB3274
Specimen Type:
Blood
Collection Volume:
Blood: 2 mL collected in a Purple Top- EDTA Tube (0.5 mL minimum)
Cause for Rejection:
Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Hemolyzed
Specimen Clotted
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Sample Exceeds Holding Time
Storage:
Refrigerated
Availability:
Mon-Fri (7:30-16:00)
Methodology:
Real-Time Polymerase Chain Reaction
Special Instructions:
If drawing >1 Thrombophilia test only 1 EDTA tube of blood is required.
Lab/Phone:
330-543-8722
TAT:
7 days
CPT Code:
81240
81241
81400 x2
81241
81400 x2
Panel Includes:
Factor V Leiden, DNA Assay
Prothrombin 20210A, DNA Assay
Factor XIII V34L, DNA Assay
and Plasminogen Activator Inhibitor-1 (PAI-1), DNA Assays
Prothrombin 20210A, DNA Assay
Factor XIII V34L, DNA Assay
and Plasminogen Activator Inhibitor-1 (PAI-1), DNA Assays
Synonyms:
Thrombophilia Panel
TH
TH
