Fillable REQUISITION FORM Telomere Length Measurements

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REQUISITION FORM Telomere Length Measurements

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Repeat Diagnostics Inc. 309-267 West Esplanade North Vancouver, BC V7M 1A5 Toll Free 1-855-295-7173 Form US032017
REQUISITION FORM
Telomere Length Measurements
Today’s date:
Store patient sample at room temperature
Do not refrigerate
PATIENT INFORMATION
Patient’s last name:
First:
Middle:
Birth Date:
mm / dd / yyyyy
Patient ID#:
Sample Collection Date
mm / dd / yyyyy
REASON FOR TESTING
! Bone Marrow Failure
! Immunodeficiency
! Lymphoid Malignancy
! Myeloid Malignancy
! Pulmonary Fibrosis
! Other Lung Disease
! Other, please specify:
ORDERING INFORMATION
Physician:
NPI#:
Hospital:
Address:
City:
State:
Zip Code:
The person listed as the Ordering Physician is authorized by law to order the test.
Authorized Signature (Required):
Results to be sent by:
! Fax:
! Email:
TEST REQUESTED
Repeat Diagnostics uses the Flow FISH procedure. Turnaround time is within 3 weeks. For expedite service, please contact us.
! 2-Panel Assay Telomere length measurements for total lymphocyte and granulocyte population only.
! 6-Panel assay Telomere length measurements for total lymphocytes and granulocytes as well as B-cells, T-cells and NK cells.
! Medical Consultation $250.00 for a written evaluation by a hematopathologist to accompany the test results. Provide pertinent patient
information, such as family history, clinical history, current working diagnosis, symptoms and lab investigations. If the
space allocated is not enough, please provide additional information on a separate sheet:
PATIENT MEDICAL INFORMATION
BILLING OPTIONS
(We do not invoice healthcare insurance companies)
Institutional Billing:
Patient Billing Credit card (VISA & MasterCard)
Hospital:
Name on Credit Card:
Department:
Address:
Contact:
City:
Address:
State:
Zip Code:
City:
Card number:
State:
Zip Code:
Exp. Date (mmyy):
CVC:
Tel:
Signature of Cardholder:
Email:
Please charge the above credit card in the amount of $
0
Repeat Diagnostics Inc. 309-267 West Esplanade North Vancouver, BC V7M 1A5 Toll Free 1-855-295-7173 Form US032017
TELOMERE LENGTH MEASUREMENTS
SPECIMEN COLLECTION AND SHIPPING PROCEDURE
Sample should only be collected and shipped on Monday, Tuesday or Wednesday.
Requisition Form check list
! Patient name is filled in and matches blood tube ID (first identifier)
! Second patient identifier (date of birth, unique ID number) is filled in and matches blood tube
! Ordering information is complete and signed by the requesting physician
! Result send out information is completed
! Assay type (2 or 6-panel) and optional consultation are selected accordingly
! Payment information is completed
Label the specimen tube with:
Patient Name and ID #
Age
Sex
Date and time of collection
Collect blood in EDTA anti-coagulant tube.
5-10ml of blood is required for successful testing.
Store patient sample at room temperature until pick-up by courier.
All blood shipments to Repeat Diagnostics must arrive within 2 days and in good condition.
SHIPPING MATERIAL
UN3373 shipping box measuring approximately 9” X 4” X 4”, labeled “Biological Substance Category B)
Specimen bag or sealable plastic bag.
Absorbent material such as paper towel.
Packing tape.
Address label.
FedEx Clinical Pak (provided free of charge from FedEx)
International Air Waybill.
Commercial Invoice.
For more information on how to ship clinical samples visit FedEx at
http://images.fedex.com/downloads/shared/packagingtips/pointers.pdf
SHIPPING
1. Place blood collection tube(s) in sealable plastic bag.
2. Place bag in shipping container. ICE PACKS ARE NOT REQUIRED
3. Place enough absorbent material in shipping container so that blood tubes do not roll around.
4. Seal shipping container with packing tape.
5. Attach address label to top of shipping container.
6. Place shipping container and requisition form inside FedEx Clinical Pak.
7. Fill out the international Air Waybill form.
8. Fill out commercial invoice form. Minimal dollar value must be $4.00 to ensure rapid customs processing.
9. Include 5 copies of the Commercial Invoice with the waybill.
10. Ship on day of collection by FedEx International Priority to:
11. Inform Repeat Diagnostics by email at test@repeatdx.com of date shipped and tracking number.
BEFORE COLLECTION OF BLOOD
SPECIMEN COLLECTION
SPECIMEN PACKING AND SHIPPING
Repeat Diagnostics Inc.
Suite 309 - 267 West Esplanade
North Vancouver, BC V7M 1A5
Canada
LAB.003.F02.00
Date of Exportation: Export References : Clinical Diagnostic Test
Shipper/Exporter (complete name and address) Consignee:
Repeat Diagnostics
Suite 309
267 West Esplanade
North Vancouver, BC V7M 1A5
Canada
T. 604-985-2609
F. 778-340-1144
Country of Export Importer same as consignee:
Repeat Diagnostics Customs Broker is :
FedEx EXPRESSCLEAR
Vancouver BC Canada
International Air Waybill No.
Marks/Nos.
No. of
Pkgs.
Type of
Packaging
Qty.
Unit of
Measure
Weight Unit Value Total Va lu e
1
Box 1 0.5 kilo 4.00 4.00
For Diagnostics Testing 0.00
Non-infectious/Non-hazardous/Non-toxic/Non-volatile
0.00
0.00
0.00
0.00
TOTAL 1 0.5 Kgs $4.00
Return to:
These commodities are licensed for the Ultimate Destination shown.
F.O.B.
Diversion contrary to United States law is prohibited.
C&F
C.I.F.
I declare all the information contained in this invoice to be true and correct.
Signature of Shipper
(Type name and title) Date
C O M M E R C I A L I N V O I C E
Country of Ultimate Destination
Canada
United States
Full Description of Goods
Fresh Cells Human White Blood Cells
United States
Country of Origin of Goods
No Commercial Value
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REQUISITION FORM Telomere Length Measurements

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Completed 26 May 2021

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