©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
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: _________________________________________
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
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.
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