TWO FORMS MUST BE SENT WITH THE SAMPLE: - Requisition Form Available in two formats, as a PDF document and as a MS Word document (last updated August 2007). Please fill in BOTH PAGES of the requisition form completely.
- Portable Document Format (PDF)
 (requires Adobe® Acrobat Reader) - Select the PDF icon below, or the link above, to open the form on your screen
- Print the form and fill in the information
- Mail the completed form with the samples to the Collagen Diagnostic Lab. See form for fax and postal mailing information.
- MS Word for Windows Format
 - Select the MS Word icon below or the link above
- The form will open in Word on your screen
- Fill out the form on your screen and print it out or save it to your hard drive
- Mail the original form with the sample to the Collagen Diagnostic Lab. You may also E-Mail a copy of the completed form as an attachment to kovacich@u.washington.edu (Subject: Requisition Form)
| Collagen Diagnostic Laboratory | Select Format | | Requisition Form | MS Word
| PDF
|
- Repository Consent Form
- What is the CDL Repository Consent?
- You are asked to give or deny permission to save and store the cells or DNA sent for laboratory testing to be used for research
- You are asked to give or deny permission to be contacted by the lab in the future to update medical information or request additional information
- Choose
- ADULT consent: Patient is 18 years of age or older
- PARENT consent: Any patient under 18 years of age
- MINOR consent: Patient age 12-17 (must accompany PARENT consent)
- MINOR CHILD consent: Patient age 7-12 (must accompany PARENT consent)
- MINOR SMALL CHILD consent: Patient < 7 years (must accompany PARENT consent)
- PROXY consent: Patient/Relative is deceased (next of kin)
- Print a copy for the patient to keep
- Send original consent with the sample
INTERNATIONAL SAMPLES Sample Shipping: An import permit is not required by the USDA in order to ship a sample to the CDL from outside the continental United States. However, to ensure that the sample arrives quickly, you may want to attach a note to the outside of the package to explain this. In the note indicate that cells or DNA are enclosed, that they are for clinical diagnostic testing and that have no commercial value. You may refer to our CUSTOMS FORM for a template. International Billing: Pre-payment for international samples is required. Click HERE for a wire transfer payment instructions. Please contact Barbara Kovacich at kovacich@u.washington.edu with any questions. Send to: Peter H. Byers, MD
Department of Pathology
Room D-518
Health Sciences Building
University of Washington
1959 NE Pacific St.
Seattle, WA 98195
Ph: 206.543.0459 | |
