Parasitetesting

Parasitology Center, Inc.
11445 E. Via Linda, #2-419
Scottsdale, AZ 85259 (480) 767-2522 Fax: (480) 767-5855

Laboratorio Analisis Clinicos
Av. Obregon 28-9
Nogales, Sonora, Mexico

REQUISITION FOR PARASITOLOGICAL DIAGNOSIS

SPECIMENS WILL BE PROCESSED ONLY WHEN ACCOMPANIED BY THIS COMPLETED FORM

How did you hear about us?

Last Name *

First Name*

Date of Birth

Height:

Weight

Gender

Male Female

Address

Address 2

Address 3

City *

State*

Zipcode*

Home Phone

Email *

Payment

Pre-paid order#

Select

Credit Card

Exp. Date:

CV2 Code

Billing Address (If not same as above)

Address

Address 2

Address 3

City

State

Zipcode

Health Care

Practitioner

Address

Fax

Bus. Phone

SPECIMEN COLLECTION DATES/COLLECTION SITE

First Stool Sample

Swab

From

Second Stool Sample

From

Blood

Other

From

History And Exposure

Foreign Travel(countries and dates with in last 5 years)

Symptoms

Past Infections and Treatments (most recent first)

Other Household Members Infected

Please Enter Text

* IN ORDER TO BILL DR., THEIR OFFICE MUST HAVE A CONTRACTUAL ACCOUNT SIGNED WITH US

Requisition Form

REQUISITION FOR PARASITOLOGICAL DIAGNOSIS

Payment

Billing Address (If not same as above)

Health Care

SPECIMEN COLLECTION DATES/COLLECTION SITE

History And Exposure