md laboratory requisition · 11182019 req nk vue - nk cell activity ... phone: 949-954-1158 fax:...
TRANSCRIPT
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: [email protected]