of 1

NAb & MxA induction assay request form

NAB request form
Published on: Mar 3, 2016
Published in: Health & Medicine      

Transcripts - NAb & MxA induction assay request form

  • 1. BLIZARD INSTITUTE NEUROIMMUNOLOGY CENTRE FOR NEUROSCIENCE AND TRAUMALaboratory contact details: BARTS & THE LONDON SCHOOL OF MEDICINE & DENTISTRY QUEEN MARY UNIVERSITY OF LONDONDr Lucia Bianchi Tel: 020 7882 2273 4 NEWARK STREET E-mail: LONDON E1 2ATDr Paul Creeke Tel: 020 7882 2486 UK E-mail: ANALYSIS REQUEST FORM TESTING FOR NEUTRALISING ANTIBODIES AND RESPONSE TO INTERFERON BETAIMPORTANTBlood samples should be collected 12-hours post-interferon beta injectionRequesting centre:Name of requesting clinician:PATIENT DETAILSSurnameForenameHospital / referencenumberDate of birth D D M M Y Y Y YCLINICAL INFORMATION REQUIREDType of interferon beta used:Time and date of last interferon beta injection:Date started on interferon beta:Does the patient suffer side effects following interferon beta injection:Has the patient relapsed whilst on interferon beta:Date of last relapse if known:SAMPLE DETAILSSerum (yellow topped tube) enclosed: Y/N MxA (Tempus tube) enclosed: Y/NDate of sample collection:Time of sample collection:Results to be sent to: Invoice to be sent to:FOR INTERNAL USE ONLY Serum sample labDate & time received numberReceived by (initials) MxA sample lab number FORM006-NABS-&-MXA-ANALYSIS-FORM No.: 006 Effective Date: 01 Mar 12 Version No.: 1.0 File name REQUEST-v1.0

Related Documents