Oct/11/2017 41 :42 AM Quest Diagnostics 949-940-7637 r ...
r-.) Quest Oct/11/2017 9:41:42 AM
Quest Diagnostics 949-940-7637
Quest Diagnostics
_.; Diagnostics"'
Account#
Ordering
1/1
Date of Collection
Physician Name
Address
Patient Date of Birth I Patient ID #/Acc #
City, State, Zip
Phone
Patient Name (Last, First)
Fax
NPI
Select:
D MS Pt Program (Medicaid patients excluded)
D Medicaid ID # and State:
Please check one ICD Code
(Required)
o Multiple Sclerosis (G35)
o Crohn's Disease (K5090)
o Other
(Please write applicable description and code)
Patient Sex
D Male D Female
TEST
91665(X) D STRATIFY JC~ Antibody ELISA (with Index) w/Reflex to Inhibition Assay
Offered for multiple sclerosis patients only.
The JC Virus (JCV) is associated with progressive multifocal leukoencephalopathy (PML). Detection of antibodies to JCV in serum or plasma is a reliable indicator of exposure to JCV. The analytical performance characteristics were determined for multiple sclerosis patients.
Do Not use this Form to order any other tests; use a separate requisition.
Visit to: ?Schedule an appointment (or call 888?277-8772) ?Find Quest Diagnostics locations (or call 800-377?8448)
Walk-in patients are always welcome
Ouest. O~Gst uicgnostts. 1119 associate ................
................
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