Reference Laboratory Request Form
BS 313 (Rev. 16) Page 1 of 2
Vitalant Center and Phone Number
For Reference Lab Only
Case Number
Date Received
Submitting Facility Information
Facility Name
Requesting Physician
Address
City
State
Account Number
Phone
Fax
Urgency of Request Complete Clinical Status Information
Routine ASAP STAT
Transfusion or Surgery Date
Patient Name
Patient ID (MRN)
Last
First
MI
Birthdate
Ethnicity
Sex M F Unknown
ABO/Rh
Sample Collection: Date
Time
Account/Admission #
Clinical Status
Diagnosis
Medications
Rhlg given? Y N
Date
IVIG Anti-CD47 Anti-CD38
Other Monoclonal Antibody Therapies
Date(s)?
Hgb/Hct
Platelet Count
Patient Bleeding? Y N
DAT Positive? Y N
Currently Pregnant? Y N
Due Date
Number of Pregnancies:
Gravida
/Para
Transfusion History
Within the last 3 months? Y N
Dates and Products
Prior to last 3 months? Y N
Dates
History of transfusion reactions? Y N
Dates
Reaction Type
History of HPC transplant? Y N
Dates
Patients Prior ABO/Rh
Donor ABO/Rh
Previous antibodies detected, check below. Other non-listed
Anti-
D
C
E
c
e
f
K
k
Fy
a
Fy
b
Jk
a
Jk
b
M
N
S
s
C
w
WAA
CAA
Red Cell Testing Request: See page 2 for sample requirements and turnaround times.
ABO discrepancy resolution
D(Rh) discrepancy resolution
Red Cell (HEA) genotype, molecular
Antibody ID
Compatibility Screen (# of units _____)
(RHCE) Red cell genotyping
Antibody titer
Elution
(RHD) Red cell genotyping
Cold agglutinin screen & titer
Transfusion reaction suspected?
Thermal amplitude
DAT
Isohemagglutination titer
Extended phenotype (serological)
Transfusion reaction suspected?
lgM IgG anti-A anti-B
Other
Reference Laboratory Request Form
BS 313 (Rev. 16) Page 2 of 2
Instructions:
1.
Contact blood center before sending samples to arrange sample pick up and/or shipping. Contact information is at
https://vitalanthealth.org/.
2.
Fill out this request form as completely as possible. Attach copies of any work performed at your facility.
3.
Label all samples with: full patient name, second unique patient identifier number, date collected. Incorrectly or
unlabeled specimens may be rejected and cannot be tested.
4.
If sending unit segments for testing, label each segment with Donor Identification Number (DIN) and include list of
DINs, segment numbers, and ABO/Rh.
5.
Update your local blood center and/or the IRL with any changes in the status of the request.
6.
Contact your local blood center to request antigen negative units.
Sample Requirements. (No gel separator tubes) For detailed list of tests and sample requirements visit
https://vitalanthealth.org/.
Test Request
Sample Requirements
Red cell/Antibody ID/Serology testing
1 clot and 4 EDTA tubes
Molecular testing (red cells)
1-2 EDTA tubes
▪ Cold Agglutinin Screen, Titer
Call for special collection instructions
▪ Donath – Landsteiner Test
▪ Thermal Amplitude Test
Approximate Turnaround Time for Preliminary Results:
Routine: Within 1-2 days
ASAP: Within 24 hours
STAT: Within 8 hours
Red cell (HEA) genotype, molecular; within 7 days
For hours of operation, contact your local laboratory.
NOTES:
▪ All TATs are measured from the time the sample is received by the testing laboratory.
▪ Complex workups may require additional time to resolve. A preliminary report will be provided.
The blood center will advise you if your sample will be forwarded to one of our network AABB Accredited IRLs.
▪ Vitalant – Phoenix IRL – 1524 W. 14
th
St., Suite 120, Tempe, AZ 85281; Phone (480) 933-7382/Fax (602) 343-7079
▪ Vitalant – Denver IRL – 717 Yosemite St., Denver, CO 80230; Phone (303) 340-1000/Fax (303) 363-2279
▪ Vitalant – Sacramento IRL – 10585 Armstrong Ave., Mather, CA 95655; Phone (916) 453-3642/Fax (916) 366-2524
▪ Vitalant – Pittsburgh IRL – 875 Greentree Road, 5 Parkway Center, Pittsburgh, PA 15220;
Phone (412) 209-7470/Fax (412) 209-7482
▪ Vitalant – Chicago IRL – 5505 Pearl St., Rosemont, IL 60018; Phone (847) 260-2505/Fax (847) 260-2409
