Please ensure private patients fill out Patient Questionnaire for Thrombophilia Screen  (see below) for billing purposes. This form ( SI-AA136) must accompany request form.  Testing will not proceed without completion of this form.

Specimens must be transported at room temperature to the laboratory in a red specimen bag ASAP. (Maximum delay to testing laboratory must not exceed 2hrs)
Coag profile, Protein C, Protein S, AT, Lupus anticoagulant, Factor V Leiden and Prothrombin Gene Mutation (PT20210) are included in a complete thrombotic screen.. If the full screen is not required, please request the desired test/s and collect 2 x 2.7 mL sodium citrate tubes.
Please ensure private patients fill out Patient Questionnaire for Thrombophilia Screen  (see below) for billing purposes. This form ( SI-AA136) must accompany request form.  Testing will not proceed without completion of this form.

Medicare states that the following criteria must be noted:
1.Patients with a first degree relative who has a proven defect of Antithrombin III,Protein C, Protein S or activated protein C. or
2.History of venus thromoboembolism.

Form SI-AA136 has the following questions to ascertain this (filled out by the patient and collector). Patients have the option to pay for the testing if the Medicare requirements are not met. (see below)

Q1. Do your parents, siblings or children have any of the following inherited blood clotting conditions (also known as a ‘thrombophilia’)? Please tick any appropriate box.
1/ Antithrombin III deficiency
2/ Protein C deficiency
3/ Protein S deficiency
4/ Activated protein C deficiency
5/ Factor V Leiden mutation or Prothrombin gene mutation
Yes, but unsure which one
No

Q2. Have you been recently diagnosed with or do you have a history of blood clots in the veins (known as “venous thrombosis”)?
These are most commonly in your lungs (known as a “pulmonary embolism” or “PE”) or legs (known as “deep venous thrombosis” or “DVT”) but can also be in the upper limb veins, cerebral veins, abdominal veins, or other less common veins.

Yes
No

Please note, if the answer to questions 1 and 2 are both no, there will be an out-of-pocket charge for this testing as it is not covered by Medicare. Prices are as follows:
Thrombotic profile $180 (includes tests 1-5 as well as Lupus Anticoagulant)
Tests 1-4 $25 per test ($25 to $100 depending on no. of tests)
Test 5 $60



Acquired deficiencies of Protein S are found in the neonatal period, pregnancy, liver disease, sepsis/DIC, nephrotic syndrome, and the acute post-thrombotic phase. Protein S is a Vit K-dependent protein and is REDUCED in patients taking warfarin. Protein S may be falsely low in acute phase conditions. Low values require repeat testing.