REQUEST FOR WHITE BLOOD CELL PREPARATION KIT

Fax form to (619) 543-3565
Note: Kits are shipped via FedEx 2-Day unless otherwise requested.

SHIPPING:
UCSD Biochemical Genetics Lab
CTF - Bldg B Room 213
212 Dickinson Street
San Diego, CA 92103
PHONE: (619) 543-5260


Number of patients?____________________

Number of controls?____________________

Needed by?___________________________

ORDERING Information:

Name of Ordering Physician: _____________________________________________

Physician Phone Number: ________________________________________________

Contact Name: _________________________________________________________

Contact Phone Number: _________________________________________________

Patient Name(s) and appointment date(s): REQUIRED

1) ______________________________________________________________

2) ______________________________________________________________

3) ______________________________________________________________

4) ______________________________________________________________

SHIPPING Information:

Name of Recipient: ________________________________________________

Phone Number: ___________________________________________________

Institution: _______________________________________________________

Building/Room: ___________________________________________________

Street Address: ___________________________________________________

City ____________________________ State & Zip ______________________


Cystinosis Central Cystine Determination Lab Cystagon Monitoring Diagnosis by WBC Diagnosis by Placenta