Hematologic Malignancy Flow Cytometry Evaluation Form
Submit clinical and specimen details for flow cytometry analysis in suspected hematologic malignancy cases.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Gender
*
Male
Female
Other
Referring Physician Name
*
First Name
Last Name
Clinical Diagnosis / Indication for Flow Cytometry
*
Specimen Type
*
Please Select
Peripheral Blood
Bone Marrow
Lymph Node
Other
Date and Time of Specimen Collection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relevant Clinical History (prior treatments, symptoms, etc.)
Tests Requested
*
Immunophenotyping
Minimal Residual Disease (MRD)
Lymphoma Panel
Leukemia Panel
Other
Flow Cytometry Findings
Rows
Marker Expression
Positive/Negative
% of Cells
CD19
1
CD20
2
CD3
3
CD5
4
CD10
5
CD34
6
CD45
7
Other
8
Interpretation / Comments
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
example@example.com
Submit Evaluation
Should be Empty: