Authorization For Test Additions and Cancellations

 Indicates field is required 
 Shipping Method:  Fed Ex
 Quick
 Sterling
 Tracking Number:
 Date:
Date Picker
 Time: :
 Client Name / Organization:
 Specimen ID:
 Contact Person:
 Email Address:   format — (test@test.com)
 Phone Number:   format — (xxx) xxx-xxxx
 LABS Accession Number:
Test Addition / Cancellation  Item #Description
0014 ABO/Rh
3725 Chlamydia/GC NAT
3588 Chagas Screen
3501 CMV IgG
3502 CMV IgM
3503 CMV Total Ab
3552 FTA-ABS
3721 HBV NAT
3747 HBV NAT
0071 Hemoglobin S
3201 Hepatitis A Antibody Screen
3202 Hepatitis A Antibody IgM
3211 Hepatitis B Core Ab Total
3212 Hepatitis B Ab, IgM
3213 Hepatitis B Surface Ab
3214 Hepatitis B Surface Ag
3215 Hepatitis B Surface Ag Neutralization
3221 Hepatitis C Ab
3222 Hepatitis C RIBA
3521 HIV 1 & 2 Ab
0072 HIV 1 EIA
0004 HIV 2 EIA
3522 HIV 1 Western Blot
0002 HIV 2 Immunoblot
3720 HIV-1/HCV NAT
3542 HTLV I/II Ab-PRISM
3543 HTLV I/II Ab-MPD
3544 HTLV I/II Ab-PRISM Filter
0235 HTLV I/II INNO-LIA
0107 IL28B
3551 RPR
0005 STS
3722 WNV NAT
Infectious Disease Profile Number:
Other:  
 
Additional Comments: