Fillable Platelet Esoteric Testing Patient Information

Fill Online, Printable, Fillable, Blank Platelet Esoteric Testing Patient Information Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Platelet Esoteric Testing Patient Information

On average this form takes 10 minutes to complete

The Platelet Esoteric Testing Patient Information form is 1 page long and contains:

  • 0 signatures
  • 2 check-boxes
  • 40 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
©2018 Mayo Foundation for Medical Education and Research MC1235-209rev1018
Platelet Esoteric Testing
Patient Information
Patient Information (required)
Patient Name (Last, First, Middle) Birth Date (mm-dd-yyyy) Gender
Male Female
Patient ID (Medical Record Number) Collection Date (mm-dd-yyyy)
Collection Time (hh:mm) am
pm
Referring Physician (Last, First) Phone Fax*
*Fax number provided must be from a fax machine that complies with applicable HIPAA regulations.
Client History (Patient and Family)
Brief description of patient’s bleeding history and clinical suspicion:
Available International Society on Thrombosis and Haemostasis (ISTH) bleeding score: _________________________________________
Medications:
Does the patient have any family history of bleeding? Yes No Information unavailable
Any other clinical history or condition (such as albinism, nystagmus, pulmonary fibrosis, splenomegaly etc.):
Ship specimens to:
Mayo Clinic Laboratories
3050 Superior Drive NW
Rochester, MN 55901
Customer Service: 855-516-8404
Billing Information
• An itemized invoice will be sent each month.
• Payment terms are net 30 days.
Call the Business Office with billing related questions:
800-447-6424 (US and Canada)
507-266-5490 (outside the US)
Visit www.MayoClinicLabs.com for the most up-to-date test and shipping information.
Patient’s Available Laboratory Results
Platelet count: ______ x10
9
/L
MPV: ______ fL
von Willebrand factor (vWF) antigen: ______ IU/dL
von Willebrand factor (vWF) activity: ______ IU/dL or %
Platelet Function Analyzer (PFA-100): Epinephrine cartridge closure time: ______ seconds
Adenosine Diphosphate (ADP) cartridge closure time: ______ seconds
Platelet Aggregation Studies:
Arachidonic acid Normal Decreased Collagen Normal Decreased
Epinephrine Normal Decreased Ristocetin (0.5 mg/mL) Normal Decreased
Adenosine Diphosphate (ADP) Normal Decreased Ristocetin (>1 mg/mL) Normal Decreased
Other agonist: ___________________________________________ ATP release Normal Decreased
Other Relevant Information:
Note: This is only for use with PTEM / Platelet Transmission Electron Microscopic Study and PLAFL / Platelet Surface Glycoprotein by
Flow Cytometry, Blood.
Instructions: To help provide the best possible service, supply the information requested below and send paperwork with the specimen.
Complete, print and submit.
Reset Form
Print
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Platelet Esoteric Testing Patient Information

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document