If testing is intended for a Medicare enrollee or Wisconsin Medicaid recipient, please download and complete the Medicare Beneficiary Form and attach below.

Sample Requirements

• Platelet Aggregation (1175) and Ristocetin Induced Platelet Aggregation (1068): Twelve (12) 4.5 mL samples in 3.2% buffered sodium citrate, glass or plastic evacuated tubes
• Single Platelet Agonist Aggregation (1250, 1255, 1260, or 1270): Six (6) 4.5 mL samples in 3.2% buffered sodium citrate, glass or plastic evacuated tubes
• Maintain whole blood sample at room temperature (do not process the sample)
• Do not send samples through a pneumatic tube system
• Notify Versiti Hemostasis Lab at 414-937-6129 when sample is drawn
• A completed Versiti Platelet Aggregation Requisition should be sent with the sample
• Transport samples and requisition to the Versiti Hemostasis lab within two hours of the draw time. Samples should be delivered to the 17th Street entrance.

Note: It is the responsibility of the drawing institution to transport the sample.

Patient Questions

10 days post-platelet transfusion is recommended, but not required.

NOTE: If platelet count is < 100,000, a platelet aggregation profile cannot be performed. A physician consult can be set up with the Hemostasis Lab Medical Director to consult with the patient’s physician. 

If looking for Bernard-Soulier Syndrome, Type 2B VWD, or Platelet-type VWD, we can perform the ristocetin aggregation (RIPA) as low as 50,000 platelet count. If the platelet count is < 50,000, the ordering physician must consult with the Hemostasis Lab Medical Director.

Please attach a summary of all medications the patient is taking and indicate which medications are being withheld prior to platelet aggregation testing.

If you would like to copy and paste or type any specific patient medication list notes, please use the field below.

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