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3023 Summit Street, Oakland, CA 94609Phone: (510) 839-5600 Fax: (510) 839-6153 PATIENT HISTORY
SUBMITTING FACILITY
Pre-Printed forms available upon request.
Platelet Count__________ (K/µL), aPTT__________ (sec.), PT__________ (sec.), INR__________ Hematocrit__________ (%), Bleeding History__________ (Y/N), Clotting History__________ (Y/N) Is this patient receiving Heparin? ( Y / N ) - please circle (LMWH or UFH or ARIXTRA) Is this patient taking Plavix? ( Y / N ) - please provide dosage__________ (mg/day)Is this patient taking Coumadin? ( Y / N ) Is this patient taking Aspirin? ( Y / N ) PANEL TESTING
MOLECULAR DIAGNOSTICS
Antiphospholipid Subgroup Panel (ACL, Phosphoserine, Phosphocholine, Phosphoglycerol, Phosphatidic Acid, Phosphoethanolamine, Phosphoinositol - IgG, IgM, IgA) Hereditary Thrombotic Risk Screen (Protein C Act, Protein S Act, AT III Act, FV Leiden) Coumadin stabilized (AT III Act, PS Antigen [Total and Free], PC Antigen, F10 Antigen, Ratio Calc.) Warfarin Sensitivity (CYP2C9*2, CYP2C9*3, VKORC1 Genotypes) Plavix Sensitivity - Genotype (CYP2C19 Genotyping) (Immunologic [ELISA] and Functional [washed-platelet Heparin-induced Platelet Activation]) Lupus Anticoagulant Screen (ACL, dRVVT, aPTT-LA) Do not reflex to LA Panel WORK-UPS (reflexive testing)
Panel (ACL, aPTT Mixing Study, Lupus Anticoagulant Index, dRVVT, Thrombin Time and PT/INR) Hypercoagulability Panel (LA Screen, Protein C Act, Protein S Act, AT III Act, FV Leiden Mutation, Prothrombin Mutation, Factor VIII Activity, Homocysteine) (Plavix Sensitivity Tests - ADP-induced Platelet Inhibition with CYP2C19 Genotype Confirmation) Prolonged aPTT and/or Prolonged PT Evaluations Von Willebrand Factor Profile Do not reflex to vWF:Multimer (May include LA Screen, aPTT Factors [8,9,11,12], PT Factors [2,5,7,10], (Factor VIII Activity, vWF:Antigen, vWF:RCo, aPTT and if indicated, vWF:Multimer) Mixing Studies, Thrombin Time, Fibrinogen Activity and/or Reptilase Time) Warfarin Sensitivity Genotype with Dose Recommendation Mild Bleeding Work-up (most common tests) (CYP2C9*2, CYP2C9*3 and VKORC1 Genotypes with Warfarin Dose Recommendation) (Plt Agg, vWF Profile, PT/INR, Fibrinogen Activity and Thrombin Time) INDIVIDUAL TEST LIST
Select Type: LMWH (__) UFH (__) ARIXTRA (__) ADAMTS-13 Activity ELISA (reflex to Inhibitor) Factor Activity (aPTT-based) test all factors Factor Activity (PT-based) test all factors PAI-1 Activity (Plasminogen Activator Inhibitor-1) Platelet Antibody ID: Direct (__) and/or Indirect (__) Platelet Aggregation Study (comprehensive) Platelet Aggregation - ASA (Aspirin sensitivity test) Factor XIII (13) Activity (screen__ or quant.__) Platelet Aggregation - RIPA (Ristocetin-induced) Warfarin Sensitivity (CYP2C9*2, *3, VKORC1) Plavix Sensitivity - LTA (ADP-induced Platelet Inhibition) ADDITIONAL INFORMATION
MD, INC. USE ONLY
Machaon Diagnostics is a PARTICIPATING PROVIDER of Medicare.
Specimen type received_________________________ Aliquots__________ Patients with insurance coverage other than Medicare are considered out-of-network and will be billedfor services not covered by their insurance provider. Medicare patients must sign an ABN, either Specimen type received_________________________ Aliquots__________ located on the reverse side of this form or downloaded from the Machaon Diagnostics website. Patient Assigned order form number______________________________________ insurance billing services are provided in accordance with the Machaon Insurance Billing Policy. HMO or medical group covered patients may need a prior authorization if they seek reimbursement.
Comments_____________________________________________________ Machaon Diagnostics is a CA-licensed, CLIA-accredited, CAP-accredited, clinical
_____________________________________________________________ laboratory approved to provide high-complexity testing services.
ONE COPY TO MACHAON DIAGNOSTICS AND ONE COPY FOR YOUR RECORDS

Source: http://clot.md/forms/pdfs/Machaon_OrderForm012012L.pdf

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