H&I test request forms

Forms

The forms collect the clinical details to enable us to perform the appropriate tests, to reflect the services currently provided by the laboratories and to comply with accreditation regulations. They may be downloaded or telephone your H&I laboratory for copies. 

• Read the guidance (PDF 1150KB) for completing the forms.
• For the Orthotype™ test request please refer to this guidance (PDF 554KB)
• Read the requirements for sample labelling
• Read the terms and conditions (PDF 310KB) for the provision of Histocompatibility and Immunogenetics 

• 3A - Platelet Refractoriness / Transfusion Reactions (PDF 115KB)

  For the investigation of:

  - Platelet Refractoriness: HLA antibody testing and typing
  - Transfusion Reactions: Transfusion related acute lung injury (TRALI) and transfusion associated graft versus host disease (TA-GvHD)
  
  

• 3B – Organ Transplant Patients and Donors (PDF 120KB)

  For the investigation of solid organ transplantation

• 3C – Haematopoietic Stem Cell Transplantation Recipients & Donors (PDF 118KB)

  For the investigation of haematopoietic stem cell transplantation

• 3D – Platelet Immunology (PDF 139KB);  

  It is important you send samples for platelet immunology testing to the Filton lab.The address is on the form above, If you send samples to another lab this can delay test results by approximately 2 to 3 days.

  For the investigation of:

  - Autoimmune thrombocytopenia and thrombasthenias
  - Fetal / neonatal alloimmune thrombocytopenia (NAIT)
  - Heparin induced thrombocytopenia (HIT)
  - Other drug-related thrombocytopenias
  - Post Transfusion Purpura (PTP)
  - HPA testing
  
  

• 3E – Granulocyte Immunology (PDF 122KB);  

  It is important you send samples for granulocyte immunology testing to the Filton lab. The address is on the form above, If you send samples to another lab, this can delay test results by approximately 2 to 3 days.

  For the investigation of:

  - Adult autoimmune neutropenia
  - Infant autoimmune neutropenia and drug-related neutropenia
  - Neonatal alloimmune neutropenia (NAIN) 
  
  

• 3F – Disease Association / Drug Hypersensitivity / H&I Research (PDF 119KB)

  For the investigation of:

  - HLA disease association

  - Drug hypersensitivity

  - H&I research
  
  

• Orthotype™ (PDF 151KB)

  For the investigation of:

  - Pre-operative evaluation for risk of metal hypersensitivity

  - Post-operative monitoring for Adverse Reaction to Metal Debris (ARMD)