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Get CA CHLA Histocompatibility Laboratory Requisition Form

Tory Medicine 4650 Sunset Boulevard Los Angeles, CA 90027 Phone: 323.361.2423, 877.543.9522 Fax: 323.361.6157 CLIA Number: 05D0542989 Ship To: Children s Hospital Los Angeles 4650 Sunset Blvd Duque Bldg., 2nd Floor, Room 2-290 Los Angeles, CA 90027 HISTOCOMPATIBILITY LABORATORY REQUISITION All information must be completed before sample can be processed See reverse side for additional information Red text indicates required information REPORTING INFORMATION PATIENT / DONOR INFORMATION.

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