Ship To ICL Tested at - In-Common Laboratories · 2020-01-03 · Ship To ICL Tested at 57 Gervais...
Transcript of Ship To ICL Tested at - In-Common Laboratories · 2020-01-03 · Ship To ICL Tested at 57 Gervais...
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Ship To ICL Tested at
57 Gervais Drive, Toronto, ON M3C 1Z2 Vancouver, BC V6T 2B5Complete and ship with specimens to ICLSubmitting Client Name and Address Shipped: mm / dd / yyyy
Ordering Clinician’s Name:
Specimen Collection Date
Month Day Year Time
Patient Name(Last, First)
Date of Birth (mm / dd / yyyy) Male
Female
Specimen # or Patient File #
For ICL use only
Specimen / Patient Label
Specimen: 5 mL serum; gel-separator tube preferred. Store and send frozen.ICL Code Test Panel ICL Code Test NameMGAP S ☐ * Myasthenia gravis Adult Reflex Panel, Serum MGTR ☐ Myasthenia gravis Treatment ResponseMGPP S ☐ * Myasthenia gravis Pediatric Reflex Panel, Serum MSKRIPA ☐ MuSK Antibodies by RIPAACHRPAN ☐ * Acetylcholine Receptor Ab Reflex Panel, Serum VGCCRIPA ☐ * VGCC Antibodies by RIPA
NABSIB ☐ * Neutralizing Antibodies to Interferon-beta* Mandatory if Provincial health plan billing eligible (except Quebec): Patient:Province: Health Number: ☐ M ☐ F
OrderingPhysician: Reg #:(Neurologist)
TITLE: Form - BC Neuroimmunology Requisition
Effective starting 1/3/2020. Document Number: PRE.154 Version: 1.0 Page 1 of 1