Fax: Clinical Diagnostic and Screening Test Requsition Form
* THIS FORM MUST BE MAILED ALONG WITH EACH SPECIMEN *
Neo Gen Screening
Courier Address
,
Phone: Fax:
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PATIENT INFORMATION DATA |
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|---|---|
| Patient Name: | |
| Sex: | |
| Date of Birth: | |
| Medical Record #: | |
| Sample Date: | |
| YOUR LAB ID: | |
| Ö | TEST REQUESTED | COST |
|---|---|---|
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Combined Acylcarnitine Profile (fatty & organic acids) & Amino Acid Profiles using Tandem Mass Spectrometry |
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| Filter Paper Blood Spot | $ 50.00 | |
| Filter Paper Plasma Spot | $ 50.00 | |
| Liquid Plasma | $ 75.00 | |
| Filter Paper Bile Spot | $100.00 | |
| CSF (liquid) | $100.00 | |
| Urine (liquid) | $100.00 | |
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Organic Acid Analysis by GC/MS |
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| Urine, Plasma (liquids) | $135.00 | |
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Amino Acid Analysis by HPLC |
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| Plasma, Urine, CSF (liquids) | $150.00 | |
| Filter Paper Blood Spot | $150.00 | |
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Inborn Error Metabolic Screen |
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| Filter Paper Blood Spot (for over 30 disorders) | $ 50.00 | |
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PKU Specialty Screening |
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| PKU Confirmatory Testing | $ 35.00 | |
| PKU Clinical Monitoring | $ 35.00 | |
| PKU Cofactor Screen (Pterins, DHPR) | $125.00 | |
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$105.00 | |
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$ 30.00 | |
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Postmortem Screen |
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| Filter Paper Blood Spot | $ 40.00 | |
To assist in the interpretation of results, please fill out form below:
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1. |
Relevant clinical information: | |
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2. |
List of current medications: | |
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3. |
Relevant lab tests: | |
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4. |
SUSPECTED DIAGNOSIS: | |
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5. |
Form completed by: | Phone #: |
SUBMITTOR INFORMATION
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Name/address/phone # of physician/health care facility to receive results: |
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| Phone: |
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Name & address of person to receive billing invoice |
| Phone: |
Another option to receiving an invoice would be to enclose a check for the amount listed above.
Neo Gen Screening does not bill insurance companies.
