The NKTI Medical Laboratory

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HEMATOLOGY REQUEST FORM

PATIENT INFORMATION
NAME: DATE OF BIRTH: / /
SURNAME GIVEN NAME MIDDLE NAME MM DD YYYY

AGE/SEX: CIVIL STATUS: CONTACT NO.: ADDRESS:

/
Diagnosis: REQUESTING PHYSICIAN

Referring Hospital/Lab:

Contact No.:

Fax/E-mail Service
Fax No.:
E-mail:

HOSPITAL/LAB INFORMATION
Charge Slip No: OR No: Hospital No:

PATIENT'S CLINICAL DATA

CBC
LEUKEMIA/LYMPHOMA PANEL COAGULATION PLATELET AGGREGATION
Did patient have history of: Did patient have history of: Did patient have history of:
1. Kidney transplantation? 1. Oral drug intake? YES NO 1. Nose bleeding YES NO
YES NO Date: Coumadin 2. Gum bleeding YES NO
Last Dose:
2. Recent surgery 3. Petechial hemorrhage YES NO
Low Molecular Weight Heparin 4. Purpura
YES NO Date: YES NO
Last Dose:
5. Ecchymoses YES NO
3. Red blood transfusion Antibiotics, please specify
6. Hematoma YES NO
YES NO No. of Units:
7. Heavy menstrual bleeding YES NO
4. Oral iron intake Last Dose:
YES NO Date:
Others, please specify
5. Injection with erythropoietin (epogen, eprex)
YES NO Date:
Last Dose:

2. Dialysis? YES NO
3. Bleeding? YES NO

SPECIMEN SUBMITTED
Whole blood in K2 Edta Whole blood in Hirudin
Plasma in 3.2% NaCitrate Body fluids, please specify
Date and Time of Collection:

HEMATOLOGY
CBC Peripheral Blood Smear
Prothrombin Time Thrombin Time DRVVT Confirm
Partial Thromboplastin Time Reptilase Time Others, please specify
Fibrinogen Level Kaolin Clotting Time
Factor VIII PT Mixing
Factor IX PTT Mixing
D-dimer DRVVT Screen

OTHERS
Reticulocyte count Malarial Count Others
Erythrocyte Sedimentation Rate Malaria Screen
Body fluid - Cell count / Diff. Count Ham's Acidified Serum Test

PLATELET AGGREGATION
Comprehensive Platelet Function Assay Aspirin Monitoring Others
Ristocetin-Induced Platelet Aggregation Clopidogrel Monitoring
Contact No.: 981-0300 loc. 1059 www.nktilab.com
 SPECIMEN GUIDELINES AND HANDLING REQUIREMENTS
Specimen / Volume Mode of Processing Releasing
EXAMINATION Method Preparation Cut-off Time
Requirements Transport Schedule of Results

CBC Automated
-
K2 EDTA anticoagulated blood (+) 10% Transport with Routine = 3 Hours
OPD STAT = 90 minutes
proportional to anticoagulant. Minimum None ice None Daily ER / IN STAT = 45
Reticulocyte Count Manual volume 2ml
-
K2 EDTA anticoagulated blood (+) 10% Transport with
Peripheral Blood Smear proportional to anticoagulant. Minimum None None Daily 2 Days
Manual ice
volume 2ml
-
K2 EDTA anticoagulated blood (+) 10% ER/IN/OPD STAT = 90
ESR Manual proportional to anticoagulant. Minimum None Transport with
None Daily minutes
volume 2ml ice
Routine = 3 Hours
Room
Ham's Acidified Serum Test Temperature =
Manual K2 EDTA anticoagulated blood - 6 ml (20 to 25 °C) With type specific donor =
None None Daily 3 hours
stable for 24
hours With out donor = 24 hours

1 ml body fluid Transport with

Cell Count for body Fluids None None Daily 3 hours
Manual ice
Cell Count for body Fluids bottle # 3 and bottle # 1. Minimum
(Cerebro Spinal Fluid) volume - 1ml None Transport with None
Manual Daily 3 hours
ice

MALARIA Immunochro- Transport with

matography Fresh anticoagulated with EDTA or ice stable for
and thick Heparin or oxalate whole blood 72 hours only None Daily 3 hours
MALARIA COUNT and thin None
microscopy

COAGULATION TESTS:
SPECIMEN REQUIRED
3 ml whole blood collected by venipuncture in 3.2% Na citrate for each test (A-line blood sample are not acceptable)
SPECIMEN COLLECTION
Preparation
Patient must be fasting, refrain from exercise and stressful activity, sample collected within 1 (one) minute of torniquet application , tube filled
without foam, prompt and adequate mixing with citrate solution for 4 (four) to 5 (five) inversions.
Mode of Transport
Transport unspun specimen to the laboratory within 1-2 hours of collection with ice ( packed with cardboard and should not be directly immersed in ice). If spun,
separate plasma using novel plastic pipettes into 2 aliquots of new cryovials wrapped in plastic bag immersed in ice.
Provincial
Freeze platelet-free specimen immediately at (-20°) or less. Ship in styrofoam insulated container with dry ice.
CUT-OFF TIME: None
PROCESSING SCHEDULE: Daily
RELEASING OF RESULT: After 3 (three) hours

PLATELET AGGREGATION TESTS

SPECIMEN REQUIRED
3 ml whole blood collected by venipuncture in Hirudin tube (arterial and A-line blood sample are not acceptable)
SPECIMEN COLLECTION
Please coordinate with the Hematology staff for the schedule, preparation and collection of sample in Hirudin tube (issued by Hematology section, Php 200.00 will be
charged for the cost of tube refundable after settling full payment of the test.
Gently invert sample tube 6-10 times to ensure complete mixing.
Inter-hospital referral: The sample should be brought to NKTI Hematology section within an hour from the time of collection. Tubes should be transported in an upright position
and care should be taken not to agitate or shake samples. (At least 12 hours notice prior to testing date)
CUT-OFF TIME: 12:00 noon of running days
PROCESSING SCHEDULE: Wednesdays of each month
RELEASING OF RESULT: After 3 (three) working days
PLATELET AGGREGOMETRY
Drugs Brand Last Dose
a) Aspirin and other antiplatelets - Clopidogrel,
Ticlopidine, Dipyridamole, Cilostazole,
Abciximab, Eptifibatide, Tirofiban
b) NSAIDS - Ibuprofen, Mefenamic acid
c) Corticosteroids
d) Antibiotics: Penicillin, Cepholosporins
e) Thrombolytic agents: Streptokinase, Urokinase
f) Local anesthetics
g) Tricyclic antidepressants
h) Chemotherapeutics
i) Food: caffeine, onion, ginger, ginko
j) Calcium channel blockers
k) Proton Pump inhibitors (Omeprazol)
HEM-QPF-001a