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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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Mole Creek & Chudleigh Visitor Information Accommodation (Note : Tariff information may change without notice. Please check when enquiring.) Blackwood Park Cottages, 445 Mersey Hill Rd, Mole Mole Creek Hotel, 90 Pioneer Dr, Mole Creek. Phone 6363 1102. Phone 6363 1208 Self-catering accommodation in two 2 bedroom Tariff from $90 to $130 double per night. Mole Creek

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Development of Ultrasonic Assisted Extraction Method of Emerging Contaminants in Freshwater Sediments Diana Nara Ribeiro de Sousa1, Guilherme Martins Grosseli1, Mariele Barboni Campanha1, Renato Lajarim Carneiro1, Antonio Aparecido Mozeto1, Pedro Sérgio Fadini1 1Universidade Federal de São Carlos – UFSCar, Rod. Washington Luís km 235, São Introduction: The determination

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