mm dd yyyy / / allergen test requisition - immunocap canada
TRANSCRIPT
Allergen Test RequisitionMM DD YYYY/ /
MM DD YYYY/ /
Please “X“ the required allergen
Patient Information
Physician Information
Last Name First Name Home Phone
Name Clinician/Practitioner Number Signature Date
Apt/Suite/Address City/Province/Postal Code
Apt/Suite/Address City/Province/Postal Code Phone Fax
Service Date:
X
OHIP Version Code Sex Date of Birth
www.cmlhealthcare.com
NOTE: Mixes may be used as a screen. If results are positive, individual allergens can be requested on the same sample up to four weeks after specimen collection. For further information please call CML HealthCare Client Services at 1-800-263-0801
MM DD YYYY/ /
LAB USE ONLYPLACE BAR CODE LABEL HERE
LAB USE ONLYPLACE TESTS LIST LABEL HERE
M/F
Allergy Testing Made Easy
The gold standard for serum allergy testing in Canada.
A simple blood test (lgE) to help diagnose allergies.
No patient preparation required (5ml sample).
ImmunoCAP is a patient or private insurance pay test.
ImmunoCAP Test Requisitions
To optimize utilization, a mixture of proper allergens have been assembled for groups of associated common allergens e.g., a mix of weeds or grass pollens.
Mixes may be used as a screen. If results are positive, individual allergens can be requested on the same sample up to four weeks after specimen collection.
For additional information, please visit www.immunocapcanada.com
Visit cmlhealthcare.com for a convenient Customer Care Center location nearest you.
Test requisition form on reverse
Over 650 allergens available for testing, including:
• Food• Peanut Components• Dust & Mites• Animals• Grass & Weed Pollens
• Tree Pollens• Insects & Venoms• Moulds & Yeast• Drugs
www.cmlhealthcare.com @cmlhealthcare
IMM.DP.01