IMMUNOSCIENCES
TEST REQUEST FORM
If the information below is incomplete or incorrectly filled out, there may be a delay in the processing of your sample.
Patient's Information
Patient's Name
First Name
Last Name
Email
example@example.com
Birth Date
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
N/A
Date & Time Collected
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Sample Collector's Initials
Address
City
State
Zip
Phone Number
Please enter a valid phone number.
Patient ID
Doctor's Information
Doctor's Name
First Name
Last Name
NPI/UPIN#
Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Fax Number
Please enter a valid phone number.
Diagnosis
Doctor's Signature
For ISL Use Only
Billing Information
Billing Information
Bill To
Practitioner
Patient
Prepaid
Cash
Check
CC
Money Order
Cardholder's Name
Credit Card No.
Expiration Date
MM/YYYY
Cardholder's Signature
Responsible Party
Responsible Party's Name
Relation to Patient
Date
-
Month
-
Day
Year
Date
Responsible Party's Signature
Tests Requested
Select your requested tests
2010 - Autoimmune Profile-Basic (ANA, RF, C1Q)
2011 - Autoimmune Panel-Comprehensive (ANA, ENA, DNA, RF, C1Q, Actin IgG, Mitochondrial IgG)
2013 - Autoimmune Liver Disease (Actin IgG, Mitochondrial IgG)
2015 - B. burgdorferi IgG, IgM by ELISA (IgG, IgM against B. burgdorferi by ELISA)
2016 - B. burgdorferi IgG, IgM by Western Blot (IgG, IgM against B. burgdorferi by Western Blot)
2017 - Immunoserology of Lyme Panel A (IgG, IgM against tickborne antigens by Multi-Peptide ELISA)
2018 - Immunoserology of Lyme Panel B (IgG, IgM against tickborne antigens by Multi-Peptide ELISA & Western Blot)
2019 - Epstein-Barr Virus (EBV) Panel (VCA IgG, IgM; EA IgG; EBNA IgG, IgM)
2020 - Viral Screen (EBV-VCA IgG, IgM; CMV IgG, IgM; Herpes 1+2 IgG, IgM)
2022 - Viral Panel Premier (EBV-VCA IgG, IgM; EA IgG; EBNA IgG, IgM; CMV IgG, IgM; Herpes 1+2 IgG, IgM; HHV-6 IgG, IgM; VZV IgG)
2023 - Viral Panel Comprehensive (EBV-VCA IgG, IgM; EA IgG; EBNA IgG, IgM; CMV IgG, IgM; Herpes 1+2 IgG, IgM; HHV-6 IgG, IgM; VZV IgG; Measles IgG, IgM)
2024 - Severe Acute Respiratory Syndrome 2 (Spike & Nucleoprotein IgG)
2025 - Autoimmune Viral Trio Panel (Spike & Nucleoprotein IgG; EBV-VCA IgG, IgM; EA IgG; EBNA IgG, IgM; HHV-6 IgG, IgM)
2036 - Long COVID Panel(Spike & Nucleoprotein IgG; EBV-VCA IgG, IgM; EA IgG;EBNA IgG, IgM; HHV-6 IgG, IgM; ANA, ENA, DNA, RF, C1Q,Actin IgG, Mitochondrial IgG)
Other
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