Protein S Activity
| 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. Protein S Activity | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
- Days Performed: Monday through Friday; 12 p.m.
- Centrifuge, remove plasma, and centrifuge again.
Please send 1 mL frozen citrated plasma.
- Males: 65-160%
- Females
- <50 years: 50-160%
- or =50 years: 65-160%

