Thrombophilia DNA Assay

Molecular Diagnostics : DNA

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. Thrombophilia DNA Assay
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

THDZ DNA1

Specimen Type:

Whole Blood

Tube Type:

Purple top (EDTA) tube (see special instructions)

Collection Volume:

2.0 mL (see special instructions)

Cause for Rejection:

Blood: Specimen clotted, stored at room temperature, > 5 days old, improper anticoagulant

Storage:

Refrigerated

Availability:

Batch testing performed once per week

Methodology:

Real-Time Polymerase Chain Reaction (PCR)

Special Instructions:

If drawing >1 Thrombophilia test only 1 EDTA tube of blood is required.

Lab/Phone:

330-543-8722

TAT:

1 week

Additional Info:

Reference range: Negative: No mutation detected.

CPT Code:

81240,81291,81241,81400x2

Panel Includes:

Factor V Leiden, Prothrombin 20210A, MTHFR 677, MTHFR 1298, Factor XIII, and PAI-1 Assays

Synonyms:

Thrombophilia Panel

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Laboratory Services

Thrombophilia DNA Assay

Molecular Diagnostics : DNA

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