EXTENDED TYPING REQUEST FORM Purchase Order No: PATIENT DETAILS DATE OF ET REQUEST: PATIENT SURNAME: NAME OF PERSON MAKING REQUEST: PATIENT FORENAME: SIGNATURE: HOSPITAL NUMBER: DATE OF BIRTH: ANTHONY NOLAN ID: CMV STATUS: BLOOD GROUP: GENDER: TRANSPLANT CENTRE: DIAGNOSIS: STATUS: Urgent/Non Urgent PROPOSED DATE FOR DATE OF DIAGNOSIS: TRANSPLANT: PATIENT HLA TYPING DETAILS HISTOCOMPATIBILITY AND IMMUNOGENETICS LABORATORY NAME: To prevent transcription errors please send a copy of the most up-to-date HLA typing report. If this is not available insert results below. HLA-A HLA-B HLA-C HLA-DRB1 HLA-DRB3,4,5 HLA-DQB1 HLA-DPB1 SELECTED DONOR IDENTIFICATION NUMBERS TYPING REQUIREMENTS Class I HLA-A Intermediate HLA-A High Resolution Class II HLA-DRB1 High Resolution HLA-B Intermediate HLA-B High Resolution HLA-DQB1 High Resolution HLA-C Intermediate HLA-C High Resolution HLA-DPB1 High Resolution DELIVERY DETAILS INVOICEE NAME: NAME: ADDRESS: ADDRESS: TEL: TEL: FAX: FAX: EMAIL: EMAIL:
EXTENDED TYPING REQUEST FORM Purchase Order No: PATIENT DETAILS DATE OF ET REQUEST: NAME OF PERSON MAKING REQUEST: SIGNATURE: PATIENT SURNAME: PATIENT FORENAME: HOSPITAL NUMBER: ANTHONY NOLAN ID: DATE OF BIRTH: CMV STATUS: BLOOD GROUP: GENDER: TRANSPLANT CENTRE: DIAGNOSIS: DATE OF DIAGNOSIS: STATUS: Urgent/Non Urgent PROPOSED DATE FOR TRANSPLANT: PATIENT HLA TYPING DETAILS HISTOCOMPATIBILITY AND IMMUNOGENETICS LABORATORY NAME: To prevent transcription errors please send a copy of the most up-to-date HLA typing report. If this is not available insert results below. HLA-A HLA-B HLA-C HLA-DRB1 HLA-DRB3,4,5 HLA-DQB1 HLA-DPB1 SELECTED DONOR IDENTIFICATION NUMBERS TYPING REQUIREMENTS Class I HLA-A Intermediate HLA-B Intermediate HLA-C Intermediate HLA-A High Resolution HLA-B High Resolution HLA-C High Resolution Class II HLA-DRB1 High Resolution HLA-DQB1 High Resolution HLA-DPB1 High Resolution DELIVERY DETAILS INVOICEE NAME: ADDRESS: TEL: FAX: EMAIL: NAME: ADDRESS: TEL: FAX: EMAIL:
Extended%20Typing%20Request%20form%20DOC1672.docx