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University of Heidelberg Department of Clinical Pharmacology and Pharmacoepidemiology - TDM Standard Request Form Sender Addressee Phone. Dr. J rgen Burhenne Analytical Chemistry Laboratory Im Neuenheimer Feld 410 D - 69120 Heidelberg Germany Fax. 49 0 6221/56-36395 Fax 49 0 6221/56-5832 juergenburhenne med*uni-heidelberg. de Email. Patient data Name First name Date of birth Sex F M Body height cm kg Dosing scheme accurate clinical data essential for interpretation of the analytical data First dose mg Maintenance dose Change of dose to Last dose before sampling x i. v* oral on since date date on date time Sampling -------------------------------------------------------------on date Written expert interpretation of the analytical data requested yes no Required sample material and costs Ideal sampling time immediately before next administration trough level more sampling points needed for determination of e*g* individual pharmacokinetics / half-life Blood sampling never from infusion system through which was applied at earlier time 2 mL centrifuged plasma Samples should be sent frozen on dry ice please announce shipment by telephone or email Date Result Signature Sender to be completed by the laboratory ID-number. Sample received. The analysis is performed by HPLC/UV after solid phase extraction in the calibrated range between 0. 2 and 10 g/mL plasma* Values 0. 2 g/mL are labelled as not detectable n*d. Analytical batch. Date of analysis. g/mL plasma Signature Laboratory This request form is assigned for one sample. For additional samples e*g* pharmacokinetic measurements please type additional request forms. Dr. J rgen Burhenne Analytical Chemistry Laboratory Im Neuenheimer Feld 410 D - 69120 Heidelberg Germany Fax. 49 0 6221/56-36395 Fax 49 0 6221/56-5832 juergenburhenne med*uni-heidelberg. de Email. Patient data Name First name Date of birth Sex F M Body height cm kg Dosing scheme accurate clinical data essential for interpretation of the analytical data First dose mg Maintenance dose Change of dose to Last dose before sampling x i. 49 0 6221/56-36395 Fax 49 0 6221/56-5832 juergenburhenne med*uni-heidelberg. de Email. Patient data Name First name Date of birth Sex F M Body height cm kg Dosing scheme accurate clinical data essential for interpretation of the analytical data First dose mg Maintenance dose Change of dose to Last dose before sampling x i. v* oral on since date date on date time Sampling -------------------------------------------------------------on date Written expert interpretation of the analytical data requested yes no Required sample material and costs Ideal sampling time immediately before next administration trough level more sampling points needed for determination of e*g* individual pharmacokinetics / half-life Blood sampling never from infusion system through which was applied at earlier time 2 mL centrifuged plasma Samples should be sent frozen on dry ice please announce shipment by telephone or email Date Result Signature Sender to be completed by the laboratory ID-number.

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