ReliantC Customer Sign-Up Form

Laboratory Information

Facility Name:  
Contact:
Facility Address:  
Phone:
   
Fax:
City:  
E-mail:
State:   Submission:
Postal/Zip:      
         

Analyzer Information
 
Make / Model
 
Serial Number
Instrument #1:  
Instrument #2:  
Instrument #3:  
Instrument #4:  
         

TriniVerical Lot Information
Select the TriniVerical Lot number currently using
       
         
         
Coagulation QC Information
Enter the lot number and expiration date for each of the control product used
         
QC Product
Lot #
 
Expiration Date
 
 
 
 
 
         

Coagulation Reagent Information
Select one (1) reagent per test; specify mechanical or optical testing; specify controls used for each
 
 
 
APTT Lot Used   Mech / Opt
Units
 
 
 
Auto D-Dimer        
 
Fibrinogen        
 
PT