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