hal agreement

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HLA Test Requisition Form
From,
Client Name:
CRM No: 
Address: 
 
To,
The Laboratory Director,
LifeCell International Private Limited,
Chennai
 
Dear Sir,
Reg: Requisition for the HLA Typing of Baby Sample
        I, hereby, request you to do the HLA typing for my baby who wants to go for stem cells treatment. Kindly oblige to my request.
 
HLA Testing to be done on: 
Treatment: 
Treatment for: 
Donor Name: 
Age: 
Gender: 
Donor CRM No: 
Date of Delivery: 
Are you sending the Recipient peripheral blood (4 mL in EDAT tube): 
(If Applicable) Recipient
Name: 
Age: 
Gender: 
 
Thank you,
Yours sincerely,
 
 
Note: The timeline for completion of testing shall maximum 14 days from the date of sample receipt.
The peripheral blood container label should have Recipient Name, Baby of, Date of Collection and Collection done by name.