md laboratory requisition · 11182019 req nk vue - nk cell activity ... phone: 949-954-1158 fax:...

NKMax America, Inc.

Notes

Physician/Client Information

Clinical Lab Test **Specimen Information must be COMPLETELY filled out for specimen collected outside NKMax Laboratory**

Patient Information

Print Name ________________________________________________Last First MI

Address________________________________________________

________________________________________________

Date of Birth___________________

Sex

Male Female Phone Number ________________________

Patient email address_____________________________

Physician Signature

X _________________________________________ ____________________________________ Ordering Physician Signature Print Name

____________________________Date (MM/DD/YY)

Tests Requested

11182019 REQ

NK Vue - NK Cell Activity

___________________________________________________

___________________________________________________

___________________________________________________

________________________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

Facility Name: ________________Processed By: ________________Incubation Start Date: __________Incubation Start Time: __________Incubation Completion Date: ___________Incubation Completion Time: ___________Temperature during incubation within 36 to 38°C? Storage temperature after incubation:

Ordering Physician Name NPI # __________________________________________ _______________________

Institution/Facility/Office Name ______________________________________________________________________

Address ______________________________________________________________________

Phone Fax __________________________________ _____________________________

Laboratory Requisition

City, State, Zip Code

Street

MM/DD/YYYY

Other

Additional Physician Name NPI # __________________________________________ _______________________

Institution/Facility/Office Name ______________________________________________________________________

Address ______________________________________________________________________

Phone Fax __________________________________ _____________________________

1) Specimen Collection

2) Specimen Processing

Yes No

1) Specimen PickupSpecimen Pickup Date: ______________Specimen Pickup Time: ______________Specimen Pickup By: ________________Storage condition at Pickup:

Specimen Received Date: ____________Specimen Received Time: _____________Specimen Received By: _______________Storage condition at Receipt:

2 to 8°C -20°C

Refrigerated Frozen

Refrigerated Frozen

NK VUE TubeStored between 2 to 8°C?Lot Number: ____________ Expiry date: _____________

SpecimenCollection Date: ___________Collection Time: ___________Collected By: ______________

Yes No

Specimen Transportation **NK Max Use Only**

2) Specimen Receipt

3001 Daimler St., Santa Ana, CA 92705 Laboratory Medical Director: Basel Kashlan, MD

CAP: 7541687 CLIA:05D2027259 Client Services Contact Information

Phone: 949-954-1158 Fax: 949-334-9124 Email: NKMClientServices@nkmaxamerica.com