Accurate filling of specimen tube essential.
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).
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.
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.

A complete Thrombotic screen includes Coag profile, Protein C, Protein S, AT, Lupus anticoagulant, Factor V Leiden and Prothrombin Gene Mutation (PT20210). If the full screen is not required, please request the desired test/s and collect 2 x 2.7 mL sodium citrate tubes.
FV Leiden and PT20210 are performed in the Haematology Molecular Laboratory.

Form SI-AA136 to be completed.
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


A complete Thrombotic screen includes Coag profile, Protein C, Protein S, AT, Lupus anticoagulant, Factor V Leiden and Prothrombin Gene Mutation (PT20210).

A thrombotic profile should not be requested in the acute post-thrombotic phase, as false LOW values for proteins such as antithrombin or protein C may be obtained. Protein C and protein S are Vit K-dependent proteins that will be reduced in patients taking warfarin. The APC resistance test is not affected by heparin or warfarin. Antithrombin should not be requested on patients receiving intravenous or subcutaneous heparin. The PCR-based tests for F Vleiden and Prothrombin 20210A can be performed at any stage.
PROTEIN C: Acquired deficiencies in neonatal period, liver disease, sepsis/DIC, and the acute post-thrombotic phase. Protein C is a Vit K-dependent protein and is REDUCED in patients taking warfarin. Levels of 60-70% represent borderline values and warrant repeat testing. - PROTEIN S: Acquired deficiencies in neonatal period, pregnancy, liver disease, sepsis/DIC, nephrotic syndrome, and in the acute post-thrombotic phase. Protein S is also 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. [Please see notes under "Antithrombin" as well]