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UCSF MOLECULAR DIAGNOSTICS LABORATORY THALASSEMIA TESTING REQUISITION FORM PATIENT NAME: DOB: SPECIMEN I.D. ETHNIC BACKGROUND Asian Afr. Amer. Middle Eastern other: SUBMITTING INSTITUTION: ORDERING

How to fill out ucsf thalassemia test requisitiondoc

How to fill out the UCSF Thalassemia Test Requisitiondoc?

1. Start by entering the requested patient information in the designated fields. This typically includes the patient's full name, date of birth, and gender.
2. Next, provide the patient's contact information, such as their address, phone number, and email if applicable. This helps the healthcare provider to reach out with any necessary updates or results.
3. Indicate the referring physician's details, including their name, contact number, and address. This information helps to establish a line of communication between the healthcare provider and the referring doctor.
4. Specify the reason for the thalassemia test requisition. This might involve indicating any symptoms, suspicions, or concerns regarding thalassemia in the patient. These details help the laboratory professionals to understand the purpose behind the test.
5. Select the requested tests related to thalassemia. These may include genetic tests to identify mutations, complete blood count (CBC), hemoglobin electrophoresis, or other specific tests as advised by the healthcare provider. Be sure to mark the appropriate checkboxes to avoid any confusion.
6. If provided, fill in the insurance information accurately. This includes the insurance company's name, policy or subscriber number, and any other relevant details. Note that this step may not be applicable if the test is self-funded.
7. Finally, sign and date the test requisition form. Your signature serves as consent for the healthcare provider to conduct the specified tests and provides an acknowledgment of the information provided.

Who needs UCSF Thalassemia Test Requisitiondoc?

1. Individuals who have a family history of thalassemia and wish to screen themselves for the condition.
2. People who exhibit symptoms such as fatigue, shortness of breath, persistent anemia, or abnormal blood test results, which may suggest a possible thalassemia diagnosis.
3. Pregnant women who may be carriers of thalassemia and want to assess the risk of passing it on to their child.
4. Healthcare professionals, including doctors, genetic counselors, and researchers, who require thalassemia testing as part of their patient care or research studies.

Remember, it is always recommended to consult with a healthcare provider to determine if the UCSF Thalassemia Test Requisitiondoc is necessary and to guide you through the process of filling it out accurately.

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