<p> ANTHONY NOLAN For barcodeHISTOCOMPATIBILITY only LABORATORIES Anthony Nolan Round Table Laboratories, Royal Free Hospital, Pond Street, London, NW3 2QG Tel: 020 7284 8337/8348, Fax: 020 7284 8301</p><p>HAEMOCHROMATOSIS MUTATION TESTING REQUEST PLEASE WRITE CLEARLY IN BLACK INK AND ONLY USING BLOCK CAPITALS *REFERRING HOSPITAL: *CONSULTANT: *TEL. No.: *DEPARTMENT: FAX / EMAIL: *PATIENT FAMILY NAME: *DATE OF BIRTH:</p><p>*PATIENT FIRST NAME: *HOSPITAL NUMBER:</p><p>GENDER: ETHNIC ORIGIN: NHS PATIENT PRIVATE PATIENT </p><p>*CLINICAL INDICATION FOR TEST: IRON OVERLOAD TRANSFERRIN SATURATION: ______% FERRITIN: ______g/L FAMILY SCREENING PLEASE GIVE DETAILS: OTHER PLEASE GIVE REASON: </p><p>OTHER DIAGNOSIS:</p><p>*DATE AND TIME OF BLOOD COLLECTION: ____ / _____ / ______, ____ : ____ am / pm PRIORITY STATUS : NORMAL URGENT </p><p>1. Please forward 4mL blood collected in EDTA (purple top tube) immediately to the address above marked ‘Haemochromatosis Testing’, for the attention of the Client Team. 2. Enclose a copy of this form. Details marked * must be completed. 3. The blood tube must have the patient’s name, hospital no. and DOB clearly identifiable. We can receive blood Mondays-Fridays 8am-5pm (if RFH tel. Ext. 37059, 34262 or 34687 for collection). 4. For RFH, samples can be deposited at the Lyndhurst Rooms (1st Floor). Samples should be placed in the box labelled ‘Anthony Nolan’ for collection. Samples are routinely collected at the end of the day. 5. Either the Clinical Indication for Test must be given, Or (for family or random screening) informed written consent for Haemochromatosis mutation testing must be obtained. THIS SECTION MUST BE COMPLETED IN FULL WHO IS RESPONSIBLE FOR THE PATIENT’S NAME OF INVOICEE: ACCOUNT? ROYAL FREE ADDRESS OF INVOICEE: OTHER TRUST (please complete box to right) PRIVATE HEALTH PLAN (complete box to right) PATIENT(complete box to right) PRIVATE HEALTH PLAN No.: If the patient is a self-payer, pre-payment will be required before we are able to release results.</p><p>For laboratory use only: Patient Number: ______Sample Number: ______Date/Time Received: ___/___/_____ , ____ : ____ am / pm</p><p>DOC479 Version 007 January 2016 Approved by: Katy Latham Author: Anila Shah</p>