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Nationa
l Jewish Health
Immunology Laboratory
1400 Jackson Street, M013
Denver, CO 80206
SHIP TO:
ADxReq-02 Functional (10/2018)
6278
.261017.ADX
4. SPECIMEN INFORMATION
Specimen Source
n Blood
Submitted By Phone Fax
S
u
bm
itt
e
r
Specimen #
S
p
e
c
ime
n
Collection Date
C
o
l
l
e
c
tion Time
1. PATIENT INFORMATION
Patient Name (Las ,t First) n Male n Female
DOB
__ __ / __ __ / __ __ __ __
7. NEUTROPHIL FUNCTION
n BACT Bactericidal Assay: S. au
reus -OR- patient isolate
Must be scheduled in advance. Call 800.550.6227
Chemota
xis
Must be scheduled in advance. Call 800.550.6227
n DHR
Dihydrorhodamine [DHR] (oxidative metabolism)
n NBT
Nitroblue tetrazolium (NBT) dye reduction (oxidative metabolism)
6. RESPONSE TO METALS
Lymphocyte proliferation to Nickel Lymphocyte proliferation to Cobalt
Lymphocyte proliferation to Chromium
8. TUBERCULOSIS TESTING
n QFT4
TB QuantiFERON
®
-TB Gold Plus In-Tube
n TSPOT
T-Spot
®
TB test
9. MISCELLANEOUS
n TH17C
Interferon Gamma and IL-17 Producing CD4 T Cells
by Flow Cytometry
n GCLS
Glucocorticoid lymphocyte stimulation
10. SPECIAL INSTRUCTIONS
INTERNAL USE
Received By Date Account# MRUN Accession
2. BILLING INFORMATION 3. REPORT DELIVERY INFORMATION
National Jewish Health Advanced Diagnostic Laboratories does not bill
patien
ts directly or third-party health insurance. Visit njlabs.org or call for
details.
Client ID
A
c
c
o
u
n
t Name
Accou
n
t N
ame Addre
s
s
C
lient ID
City
State
Address
C
it
y
P
h
o
n
e Fa
x
P
h
o
n
e S
e
c
u
r
e
Fax
5a. LYMPHOCYTE PROLIFERATION ASSAYS (MITOGEN/ANTIGEN RESPONSE)
Lymphocyte proliferation to PHA mitogen Lymphocyte proliferation to Candida antigen
Lymphocyte proliferation to Con A mitogen Lymphocyte proliferation to Tetanus antigen
Lymphocyte proliferation to PWM mitogen
n LSTIM
Lymphocyte proliferation to all 3 mitogens (PHA, ConA, PWM)
+ 2 antigens (Candida, Tetanus)
5b. For volumes < 2mL, lymphocyte proliferation can be performed on whole blood.
Whole blood lymphocyte proliferation to PHA mitogen Whole blood lymphocyte proliferation to Candida antigen
Whole blood lymphocyte proliferation to Con A mitogen Whole blood lymphocyte proliferation to Tetanus antigen
Whole blood lymphocyte proliferation to PWM mitogen
Immunology Laboratory
|
800.550.6227
|
303.270.2175 fax
|
njlabs.org
Immunology Functional Assays Requisition
LMITO
LMITO
LMITO
LANTI
LANTI
WBMIT
WBMIT
WBMIT
WBANT
WBANT
NILPT
CRLPT
COLPT
CHTX
Zip
Phone
Secure Fax
State
Duplicate Report Request Attention:
Zip
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Completed 2 March 2021

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