FOR LABORATORYPARASITIC DISEASE USE ONLYCONSULTANTS Lab #

Request Form for Parasite Serology Studies

Please provide Physician or Institution

Name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Phone

Please provide Patient Information

First Name
Middle Name
Last Name
Pt. ID #
Spec. #
Date and time Specimen Collected

Patients Date of birth
Patient's Sex	Male Female
Patient's Short Clinical History

Test Required

Amebiasis-EIA

Ascaris-EIA

Angiostrongylus-EIA

Chagas' Disease-EIA

Chagas' Disease-PCR

Cysticercosis-EIA

Cysticercosis-CSF-WB

Echinococcus - IHA

Filariasis -IHA

Fasciola-EIA

Leishmaniasis-IFA

Malaria-P.falcip-IFA

Malaria-Screen-IFA

Malaria-Speciation-PCR

Paragonimus-EIA

Schistosomiasis-EIA

Strongylodiasis-EIA

Toxocara-EIA

Toxoplasmosis-IHA

Trichinosis-EIA

                  

ALL TESTS DETECT THE IgG4 ANTIBODY

Notes: