CENTRAL FLORIDA CENTRAL FLORIDA RESEARCHRESEARCH

Instructions on collecting & Instructions on collecting & packing specimens for packing specimens for

shipping by FedEx Expressshipping by FedEx Express

KIT CONTENTSKIT CONTENTS

1 EDTA Tube1 EDTA Tube 1 Styrofoam Box1 Styrofoam Box 1 Biohazard bag1 Biohazard bag 1 Requisition1 Requisition 1 Kit Request Form1 Kit Request Form 1 Biohazard Label1 Biohazard Label

Test DescriptionsTest Descriptions

REQUISITIONREQUISITION & PAYMENT & PAYMENT A licensed physician or nurse practitioner must A licensed physician or nurse practitioner must

order the test.order the test.

Complete and enclose Test Requisition. Complete and enclose Test Requisition.

Be sure to check the test(s) ordered Be sure to check the test(s) ordered

Complete credit card information. Complete credit card information.

Physician information and Patient Information Physician information and Patient Information must be complete. The requisition must be signed must be complete. The requisition must be signed by the physician in the physician information at by the physician in the physician information at top of requisition and by the patient or responsible top of requisition and by the patient or responsible party at the bottom of the requisitionparty at the bottom of the requisition..

REQUISITIONREQUISITION Physician NPI#______________UPIN Physician NPI#______________UPIN

#_____________________Central Florida Research, Inc.#_____________________Central Florida Research, Inc.

Physician______________________________________________342 E. Physician______________________________________________342 E. Central AvenueCentral Avenue

Address:_______________________________________________WinteAddress:_______________________________________________Winter Haven, Florida 33880r Haven, Florida 33880

City: City: _________________________________________________Phone (863) _________________________________________________Phone (863) 299-3232299-3232

State: ________________________Zip Code: State: ________________________Zip Code: ______________________________ Fax: (863) 299-3355Fax: (863) 299-3355

Phone Phone Number: ________________________________________Number: ________________________________________Website: Website: centralfloridaresearch.com

Fax Number: Fax Number: __________________________________________CLIA NUMBER: __________________________________________CLIA NUMBER: 10D105948110D1059481E-mail: _______________________________________________STATE E-mail: _______________________________________________STATE OF FLORIDA LICENSE # 800021816OF FLORIDA LICENSE # 800021816

Account Number: Account Number: ______________________________________ ______________________________________ PHYSICIAN’S SIGNATURE REQUIRED PHYSICIAN’S SIGNATURE REQUIRED Physician’s Physician’s Signature____________________________________TEST Signature____________________________________TEST REQUISITIONPATIENT NAME: REQUISITIONPATIENT NAME: F M / / F M / / Last Name First Last Name First Name MI Sex Name MI Sex Date of Birth AgeSS# Date of Birth AgeSS# ADDRESS: ADDRESS: Street City Street City ST ST Zip CodeSPECIMEN SOURCE:Whole Zip CodeSPECIMEN SOURCE:Whole BloodCollected by:SerumDate: Time: BloodCollected by:SerumDate: Time: TEST NAMETEST METHODACCESSION TEST NAMETEST METHODACCESSION NUMBER:Borrelia burgdorferi Direct Fluorescent NUMBER:Borrelia burgdorferi Direct Fluorescent Antibody by Flow Cytometry Antibody by Flow Cytometry DFADiagnosis:ImmunoDOT™Borrelia burgdorferi DFADiagnosis:ImmunoDOT™Borrelia burgdorferi Screening TestEIA DOT BLOT ATTENTION: PLEASE Screening TestEIA DOT BLOT ATTENTION: PLEASE ANSWER THE FOLLOWINGANSWER THE FOLLOWING

QUESTIONS AND CHECK THE SYMPTOMS THAT APPLY! QUESTIONS AND CHECK THE SYMPTOMS THAT APPLY! Please answer the following questions: 1. Have Please answer the following questions: 1. Have you had a tick Bite? __________ If so, when? you had a tick Bite? __________ If so, when? ___________and in what state?_______________ 2. ___________and in what state?_______________ 2. Symptoms: ____ Erethema Migrans {Bullseye Rash) Symptoms: ____ Erethema Migrans {Bullseye Rash) ____ Chills & Fever ____Fatigue ____ Headache ____ Chills & Fever ____Fatigue ____ Headache _____ Muscle &Joint Pain ____ Numbness and Pain _____ Muscle &Joint Pain ____ Numbness and Pain in Arms & Legs ____ Paralysis of Facial Muscles ____ in Arms & Legs ____ Paralysis of Facial Muscles ____ Meningitis–fever stiff neck, severe headache____ Meningitis–fever stiff neck, severe headache____ Abnormal Heart Beat ____ Chronic Lyme Arthritis ____ Abnormal Heart Beat ____ Chronic Lyme Arthritis ____ Nervous System Problems including Memory loss and Nervous System Problems including Memory loss and difficulty concentrating____ Unrestful Sleep difficulty concentrating____ Unrestful Sleep Date of Onset of Symptoms: Date of Onset of Symptoms: __________________Sample/Data collected may be used __________________Sample/Data collected may be used for verification of test protocols and for research for verification of test protocols and for research purposes. No identifying information will be included purposes. No identifying information will be included with patient samples/data used for research.METHOD with patient samples/data used for research.METHOD OF PAYMENT: I HEREBY AUTHORIZE CENTRAL OF PAYMENT: I HEREBY AUTHORIZE CENTRAL FLORIDA RESEARCH, INC TO CHARGE$ TO FLORIDA RESEARCH, INC TO CHARGE$ TO MY: VISA MasterCard MY: VISA MasterCard American Express Debit Card Credit Card American Express Debit Card Credit Card Number Number Expiration Date:Credit Card Statement Expiration Date:Credit Card Statement Address:City Address:City ST Zip ST Zip CodeTelephone # ( ) - CodeTelephone # ( ) - Authorization Number (last 3 digits on back of Authorization Number (last 3 digits on back of card):Patient Name:(No Personal Checks Please). card):Patient Name:(No Personal Checks Please). TOTAL TOTAL AMOUNT:Card Holder Signature: AMOUNT:Card Holder Signature: _____________________________________________________________________________________________________________________________________________ _____________________ Signature required to authorize testing and Signature required to authorize testing and charges.___ Please check if you would like charges.___ Please check if you would like receipt.receipt.Rev. 1/9/08 by pp, 2/12/08, 6/16/08, 10/02/08, Rev. 1/9/08 by pp, 2/12/08, 6/16/08, 10/02/08, 10/28/08, 3/24/1010/28/08, 3/24/10

Rev. 1/9/08 by pp, 2/12/08, 6/16/08, 10/02/08, 10/28/08, 3/24/10

Physician NPI#______________UPIN #_____________________ Central Florida Research, Inc. Physician______________________________________________ 342 E. Central Avenue Address:_______________________________________________ Winter Haven, Florida 33880 City: _________________________________________________ Phone (863) 299-3232 State: ________________________Zip Code: _______________ Fax: (863) 299-3355 Phone Number: ________________________________________ Website: centralfloridaresearch.com Fax Number: __________________________________________ CLIA NUMBER: 10D1059481 E-mail: _______________________________________________ STATE OF FLORIDA LICENSE # 800021816 Account Number: ______________________________________ PHYSICIAN’S SIGNATURE REQUIRED Physician’s Signature____________________________________

TEST REQUISITION PATIENT NAME: F M / / Last Name First Name MI Sex Date of Birth Age SS# ADDRESS: Street

City ST Zip Code

SPECIMEN SOURCE: Whole Blood Collected by: Serum Date: Time:

TEST NAME

TEST

METHOD

ACCESSION NUMBER:

Borrelia burgdorferi Direct Fluorescent Antibody by Flow Cytometry

DFA

Diagnosis:

ImmunoDOT™ Borrelia burgdorferi Screening Test

EIA DOT

BLOT

ATTENTION: PLEASE ANSWER THE FOLLOWING QUESTIONS AND CHECK THE SYMPTOMS THAT APPLY! Please answer the following questions: 1. Have you had a tick Bite? __________ If so, when? ___________and in what state?_______________

2. Symptoms: ____ Erethema Migrans {Bullseye Rash) ____ Chills & Fever ____Fatigue ____ Headache _____ Muscle &Joint Pain ____ Numbness and Pain in Arms & Legs ____ Paralysis of Facial Muscles ____ Meningitis–fever stiff neck, severe headache

____ Abnormal Heart Beat ____ Chronic Lyme Arthritis ____ Nervous System Problems including Memory loss and difficulty concentrating ____ Unrestful Sleep Date of Onset of Symptoms: __________________

Sample/Data collected may be used for verification of test protocols and for research purposes. No identifying information will be included with patient samples/data used for research. METHOD OF PAYMENT: I HEREBY AUTHORIZE CENTRAL FLORIDA RESEARCH, INC TO CHARGE

$ TO MY: VISA MasterCard American Express Debit Card Credit Card Number Expiration Date: Credit Card Statement Address: City ST Zip Code

Telephone # ( ) - Authorization Number (last 3 digits on back of card): Patient Name:

(No Personal Checks Please). TOTAL AMOUNT:

Card Holder Signature: _________________________________________________________________________________ Signature required to authorize testing and charges. ___ Please check if you would like receipt.

Test Requisition Form

SPECIMEN COLLECTIONSPECIMEN COLLECTION Clean the arm and top of tubes with PVP-Iodine or other Clean the arm and top of tubes with PVP-Iodine or other

anti-bacterial prep.anti-bacterial prep.

For Borrelia burgdorferi Immunodot Antibody Detection For Borrelia burgdorferi Immunodot Antibody Detection Screening Assay:Screening Assay:

Collect 1 SST Gel Separator Tube, allow to clot.Collect 1 SST Gel Separator Tube, allow to clot. Centrifuge for 10 minutes to separate the serum.Centrifuge for 10 minutes to separate the serum.

For Borrelia burgdorferi Direct Fluorescent Antibody Test For Borrelia burgdorferi Direct Fluorescent Antibody Test with enumeration and Quantification by Flow Cytometry:with enumeration and Quantification by Flow Cytometry:

Collect 1 EDTA (Lavender Stopper) Tube and mix Collect 1 EDTA (Lavender Stopper) Tube and mix well by gently rocking the tube back and forth.well by gently rocking the tube back and forth.

LABEL TUBES AND TAPELABEL TUBES AND TAPE Label tubes with patient’s Name, ID number (can Label tubes with patient’s Name, ID number (can

be SSN, birthdate or Patient Account Number), be SSN, birthdate or Patient Account Number), Date, Time collected and Initial of phlebotomist.Date, Time collected and Initial of phlebotomist.

Information on tubes must match requisition or Information on tubes must match requisition or specimen will be rejected.specimen will be rejected.

Cut two 3 inch long strips of ¾ inch wide tape to secure Cut two 3 inch long strips of ¾ inch wide tape to secure the rubber stopper of each filled specimen tube. Use the the rubber stopper of each filled specimen tube. Use the first strip of tape over the top of the rubber stopper and first strip of tape over the top of the rubber stopper and down along opposite sides of the tube. Use the second down along opposite sides of the tube. Use the second strip of tape to wrap around the specimen tube and also strip of tape to wrap around the specimen tube and also cover the cut ends of the first strip of tape.cover the cut ends of the first strip of tape.

LABEL TUBES AND SECURELY LABEL TUBES AND SECURELY TAPETAPE

PACKING SPECIMEN FOR PACKING SPECIMEN FOR SHIPMENTSHIPMENT

1.1. Place the tubes in the Styrofoam Place the tubes in the Styrofoam Container with the absorbent Container with the absorbent material and tape around the entire material and tape around the entire container. Put the Styrofoam container. Put the Styrofoam Container in a biohazard bag. Container in a biohazard bag.

2. Place the Biohazard Bag in a shipping container with the Requisition…

Packing SpecimenPacking Specimen

SHIPPING SHIPPING Place a frozen ice pack (not included) in the FEDEX Place a frozen ice pack (not included) in the FEDEX

overnight shipping envelope or container.overnight shipping envelope or container.

The package The package mustmust identify its contents as identify its contents as “Diagnostic Specimens”.“Diagnostic Specimens”.

Ship specimens by overnight courier Monday Ship specimens by overnight courier Monday through Thursday. The lab is through Thursday. The lab is closedclosed on Saturday on Saturday and Sunday.and Sunday.

Specimens must be received within 48 hours of collection.

SPECIMENS RECEIVED OVER 48 HOURS FROM SPECIMENS RECEIVED OVER 48 HOURS FROM

COLLECTION MAY BE REJECTED.COLLECTION MAY BE REJECTED.

PACKAGE CONTENTSPACKAGE CONTENTS

+ + + +

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SHIPPING OUTSIDE OF U.S.A.SHIPPING OUTSIDE OF U.S.A.

For all specimens shipped from For all specimens shipped from outside the U S, please complete outside the U S, please complete

Shipping Specimen Invoice Shipping Specimen Invoice for for CustomsCustoms

Contact UsContact Us

Address:Address:• 342 E. Central Ave.342 E. Central Ave.

Winter Haven, Florida 33880Winter Haven, Florida 33880 CFR is open Monday - Friday from 8:30 CFR is open Monday - Friday from 8:30

a.m. - 4:00 p.m. EST (GMT -5:00)a.m. - 4:00 p.m. EST (GMT -5:00)Phone Number: (863) 299-3232Phone Number: (863) 299-3232Fax Number: (863) 299-3355Fax Number: (863) 299-3355

www.centralfloridaresearch.com