Lancet Labs Request Form

MOLECULAR DIAGNOSTIC SERVICES (PTY) LTD
Reg. No. 200100177907
6 Ribston Place
Private Bag X20
Westville 3630, South Africa
Tel: +27 31 267 7000
Fax: +27 31 267 7005
Email: [email protected] www.mdsafrica.net
VAT Reg No. 4270210554
Practice No. 050 000 0235660
ATT: Lancet
RE: Instructions for ImuPro samples for MDS
Lancet Laboratory use only:
Please collect 1 x yellow top container (follow standard phlebotomy practice for whole blood)
Place a laboratory requisition number on the tube.
Log to the client 00MDSKZN.
Log the test RMDS.
Please fill in all details on the MDS requisition form (2nd Page) and send the form with the
sample
This will be shipped to KZN Lorne Street - Location 9400.
Lorne Street must call MDS once the sample has arrived so MDS can arrange a collection.
Please note: the client does not need to pay Lancet for the blood sample, the client only pays
MDS to do the test
For any queries, please contact Robyn on 031 267 7000.
A division of Molecular Diagnostics Services (Pty) Ltd, Practice No. 050 000 0235660
6 Ribston Place, Westville, 3629, Pvt.Bag X20, Westville, 3630, South Africa
Tel: +27 31 267 7000 , Fax: +27 31 267 7005 , Email: [email protected]
www.wellpro.co.za
ADM RQT-0041-5
Client Details (Note: These tests are not covered by Medical Aid)
Sex:
*results are emailed
Male
Female
First Names:
Surname:
Age:
ID No.:
Date of Birth:
Tel:
Fax
Cell:
e-mail:*
Physical Address:
Postal Address:
How did you hear about ImuPro?
Referring Practitioner: (requiring copy of results)
Address:
Tel:
Fax
Cell:
e-mail:
Nature of symptoms:
Details of Present Medication:
Any other comments:
Date blood taken:
Phlebotomist (Name/Clinic/Lab):
COST PER TEST (Incl. VAT) - TEST PANELS (Please )
ImuPro Food Hypersensitivity PreScreen (7 Food pool groups)
R 950.00
ImuPro 100 Food Hypersensitivity Test (90 Food Allergens)
R 2250.00
ImuPro 300 Food Hypersensitivity Test (271 Food Allergens)
R 4550.00
It is recommended that no food is eaten 2-4 hours prior to the blood sample being taken. A 5ml serum sample (Gel/SST Plain tube) of blood is
required for this test to be sent to the MDS laboratory for analysis. Please place the tube back in the MDS kit display pack, place it in the
fridge and send it to the MDS laboratory either by courier or speed post within 48hrs. Results may take up to 10-14 working days.
Limitations of the method
The results obtained must always be interpreted in combination with the complete clinical picture and dietary changes must be made in
consultation with a relevant dietician or nutritional expert. The IgG levels determined by using this test system make it possible to infer
information about the degree of sensitization of the patient to the food antigens or mixtures tested. They cannot be used to derive a
relationship between the determined IgG concentration and occurrence of serious clinical symptoms. False positive test results may be
produced by cross-reactivity of the antigens being tested with the epitopes of other antigens.
Certain allergy associations do not support IgG testing as a means to diagnose food hypersensitivities. However, a growing number of
publications and a large amount of anecdotal evidence support that elimination diets based on circulating IgG antibodies result in improved
symptoms in patient. A subset of these peer reviewed published papers are found on our website www.wellpro.co.za.
Client to sign acceptance of limitations of the method before sample is sent to MDS and testing is started: __________________________
Payment details: Per attached cheque, credit card, bank deposit or electronic transfer with name reference.
rd
Please DO NOT pay any 3 party. If you would prefer to give us your credit card details telephonically, then please
contact the office on 031 267 7000.
Note: The sample is invalid for processing after 1 month therefore payment or upgrade requests are required within 1 month. Please note that the
test will not be started without payment having been made.
Credit Card Details: (please )
Visa
Master Card
Card Number:
CVV Number:
American Express
Budget 6m
Exp Date:
Straight
Amount:
Signature:
Name on card:
Banking Details: Molecular Diagnostic Services (Pty) Ltd
Bank: FNB Westville
Account Number: 62109297912
Branch Number: 223526
MDS REF No
A division of Molecular Diagnostics Services (Pty) Ltd, Practice No. 050 000 0235660
6 Ribston Place, Westville, 3629, Pvt.Bag X20, Westville, 3630, South Africa
Tel: +27 31 267 7000 , Fax: +27 31 267 7005 , Email: [email protected]
www.wellpro.co.za
ADM RQT-0041-5

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