Patient questionnaire S-AA136 must be completed and sent with samples.
Ensure samples will reach the laboratory within 4 hours of collection.  For specimens collected at an external laboratory (non-Mater), samples must be double spun and frozen immediately before transporting on dry ice to Mater laboratory.
Minimum collection of 1.8 mL is recommended and the tube must be filled to the line to be acceptable (usual blue top collection protocol.) If a thrombotic screen is requested 3 citrate tubes is sufficient for Lupus, APC resistance, Protein C, Protein S.

Patient questionnaire S-AA136
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


Secondary causes for APC resistance include oral contraceptives, pregnancy, hormone replacement therapy, and the antiphospholipid syndrome. A positive APC resistance test should be followed up by a PCR test for F V Leiden. The APC resistance test is not influenced by heparin, but should ideally not be performed on patients taking warfarin.

Coagulation laboratory performs functional/clotting based assay. Mutation analaysis for the Factor V Leiden mutation and the Prothrombin 20210 mutation is performed by the Haematology Molecular laboratory.