A randomised trial of treating Fibroids with Embolisation or Myomectomy to Measure the Effect on quality of life among women wishing to avoid hysterectomy

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FEMME – SAMPLE TRANSFER FORM A randomised trial of treating Fibroids with Embolisation or Myomectomy to Measure the Effect on quality of life among women wishing to avoid hysterectomy FEMME SAMPLE TRANSFER FORM HOSPITAL: Patient Initials Date of Birth FEMME Trial Number Date of Sample Was the sample taken on day 2, 3 or 4 of period (YES or NO) Date sample spun and put in Freezer Date sent to FEMME trials Office Your name (CAPITAL LETTERS) Signature Comments DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY PLEASE COMPLETE THIS FORM AND INSERT IT IN WITH THE SAMPLES RETURNED TO THE BCTU IN THE ROYAL MAIL SAFE BOX PROVIDED. POSTAGE HAS BEEN PAID ON THESE SAFE BOXES. PLEASE ENCLOSE A COPY OF THE PATIENT’S CONSENT FORM WITH THE BLOOD SAMPLES. PLEASE RETURN THE SAMPLES TO: FEMME TRIAL, BCTU, ROBERT AITKEN INSTITUTE, UNIVERSITY OF BIRMINGHAM, BIRMINGHAM, B15 2TT. PLEASE TELEPHONE 0121 414 8335 IF YOU HAVE ANY QUERIES.