Full Thrombophilia Panel, 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. Full Thrombophilia Panel, DNA Assay
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

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

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

Synonyms:

Thrombophilia Panel
TH

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Full Thrombophilia Panel, DNA Assay

Molecular Diagnostics - : DNA

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