Anthony Nolan Histocompatibility Laboratories
Patient Histocompatibility Testing
Consent Form
Accredited Medical Laboratory Accredited
Reference No: 1517 / / HISTOCOMPATIBILITY TESTING REQUEST
Tel: 020 7284 8303/8348,
Fax: 020 7284 8301,
ANTHONY NOLAN HISTOCOMPATIBILITY LABORATORIES
77B Fleet Road, Hampstead, London NW3 2QU
Each specimen MUST be clearly labelled with FULL name and DOB and either Hospital number or
NHS number or address. Samples cannot be accepted without the following information in full.
FIRST NAME Please print FAMILY NAME Please print DATE OF BIRTH
…………...………………………………………………………………………………………………………………………………………………………/…………/……
HOSPITAL NUMBER (if registered) NHS NUMBER GENDER Male Female
…………………………………………………………………………………………………………………………………………………………………………………………
ETHNICITY White Black/African/Caribbean Asian Mixed (please describe) Other (please describe)
…………………………………………..
ADDRESS including postcode
………………………………………………………………………………………………………………………………………………………
TRANSPLANT CENTRE TRANSPLANT CONSULTANT/CONTACT
……………………………………………………………………………………………………………………………………………………….
SPECIMEN INFORMATION: Blood DNA saliva kit Buccal swab other
COLLECTION DATE: TIME: BY:
………/………/……………………………………………………...... / Transplant date: ………………………………………
Treatment start date: ………………………………….
Is this person a PATIENT? If yes please provide the following….
DIAGNOSIS and DIAGNOSIS DATE
…………………………………………………………………………………………………………….
Has this patient been transfused in the last 7 days? Yes No
Details………………………………………………………………………………….. / CURRENT WBC x 109/l (if known)
………………………………………………………..
NHS Private Patient
Is this person a POTENTIAL DONOR or FAMILY MEMBER to a patient? If yes please provide the following…
RELATED PATIENT’S FIRST NAME………………………………………… RELATED PATIENT’S FAMILY NAME ………………………………………. RELATED PATIENT’S DOB…..……………………………………………………………………………………………………………………………………….
RELATED PATIENT’S HOSPITAL No. ……………………………………… RELATED PATIENT’S NHS No. ……………………………………………
RELATIONSHIP OF DONOR TO PATIENT Sibling Parent Other (please provide)
………….…………………………………………………………………………………………………………………………………………………………
IF URGENT PROCESSING IS REQUIRED, PLEASE EMAIL:
CONSENT: Please ensure the accompanying consent form (Page 2) is completed.
TESTS REQUESTED:
(i) Initial HLA typing or Confirmatory typing
HLA typing plus CMV testing and ABO blood grouping
- 2 x 4ml tubes of venous blood taken into EDTA and 1x 4ml tube clotted
Recommended for patients prior to HLA mismatched transplants only.
- 1 x 10ml clotted sample from the patient
Forward blood immediately to the laboratory at the address above marked FAO Clinical Services. We can receive blood Mondays-Fridays 8am-5pm. PLEASE DO NOT REFRIGERATE BLOOD.
THIS SECTION MUST BE COMPLETED IN FULL:
NAME OF INVOICEE:……………………………………… …………… ORDER/REFERENCE NOS:………………………………
ADDRESS OF INVOICEE:…………………………………………………………………………………………………………………………
If the patient is a self-payer, pre-payment will be required before we are able to release results
For laboratory use only
Patient Number ______Time / Date Received ______
Sample Number ______Booked by (Initials) ______
Name of patient:I agree to my blood and DNA being tested for:
Histocompatibility factors,
CMV virology
blood group type
all of which are important factors for the identification of a haematopoietic stem cell donor for transplantation.
I agree that a small quantity of my blood and DNA will be retained by the laboratory for any future tests required relating to my transplant. / yes no
yes no
The laboratory may also undertake studies of immunological markers that may be of importance in transplantation in the future, particularly in identifying optimum donors. Although this may not necessarily affect my transplant, I agree that some of my stored blood or DNA may be used anonymously in these studies for the benefit of other patients. / yes no
I give explicit consent to Anthony Nolan to process any sensitive personal data* relating to me, held by it.
* In order to be able to assess you for the purposes of matching and donor selection, we will collect data which the Data Protection Act defines as sensitive, such as ethnicity). / yes no
Signature of consenting individual:
Name and relationship of consenting individual, if different from above named patient:
Date completed:
DOC2857 Version 004 April 2016
Approved by Katy Latham Page 1 of 2 Author: Vivien Hanson