CUSTOMER INFORMATION

Lead Submitted By:
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LAB INFORMATION

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DNA INFORMATION

DNA Test Type:
Chain of Custody?: Immigration?: Need Rapid Results?:
Paternity:
Family Relationship:
Ancestry:
Forensic:
Maternity:

Relationship to tested Parties:
Are All Parties Testing:

STD INFORMATION

Chlamydia: Chl/Gon: CBC (Complete Blood Count): HIV DNA PCR: HIV RNA PCR:
Hepatitis B: Herpes Type 1 IgG: Herpes Type 2 IgG: Herpes Type 1&2 IgG: Herpes 1&2 IgM:
HIV 1&2 Antibody: Gonorrhea: RPR Syphilis: HIV 1/O/2 Antigen/Antibody (4th Gen): Hepatitis C:
Urinalysis:

DRUG INFORMATION

Test Profile: Occupational Testing: 9 panel: Radar 10 Panel:
Hair Follicle 5 Panel: Radar 6 Panel:

WELLNESS INFORMATION

Rheumatoid Arthritis: Treponema pallidum DNA PCR (QD): THYROID PANEL WITH TSH(QD): THYROID PANEL w t3,t4,FTI (QD): Iron(TIBC):
T3, FREE(QD): (T4): Prealbumin: FTA-ABS(QD): Prostate (PSA):
T3 UPTAKE(QD): LIPID PANEL (QD): HEMOGRAM(QD): TSH (QD): Thyroid Profile:
GLUCOSE, FASTING(QD): GLUCOSE, SERUM(QD): ALT (QD): AST (QD): BILIRUBIN(QD):

PAYMENT INFORMATION

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