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REQUISITION AND ORDER/ENTRY INFORMATION FOR IMMUNOGENETICS & TRANSPLANTATION


 A requisition must accompany all samples.

1.  Patient information:

         - Legal full name

         - Sex

         - Date of Birth

         - Social Security Number (required for solid organ transplant recipients)

         - Medical Record Number

         - ICD-9 Code

         -  Patient registration or bulk account number

2.  Date and time of sample collection

3.  Specimen source (i.e., peripheral blood, bone marrow, etc.)

4.  Name and phone number of requesting physician

5.  Test or testing protocol requested

6.  Address to which written laboratory report should be sent

 

Any referrals for HLA typing or histocompatibility testing must additionally include:

     a. Subject’s status (kidney recipient, related donor, etc.)

     b. Relations to prospective recipient, if applicable

     c. Subject’s reacial or ethnic background

     d. Transplant date, if known