TEST REQUEST FORM           Wisconsin Viral Research Group                     www.wisconsinlab.com

Enclose completed form with sample.                                                                                  Rev 050702

I. Patient Information:

Name: (last, first)                                                                          Date of Birth:                                 M / F

Address:

Phone:

II. Ordering Physician Information: Important: Please include a fax number for result reporting.*

Name:                                                                                                               UPIN#:

Address:

City, State, Zip

FAX RESULTS TO:                                                 Phone:                                      Contact person:

III. Payment Information: Please note: Our laboratory does not bill patients, patient's insurance, or Medicare

Patient Prepaying By: (circle one)         Check           Money Order                Credit Card (fill out information below)

Name on Credit Card:

Credit Card Information: (circle one) VISA MasterCard Note: We do not accept American Express

Credit Card No: l      l      l      l      l - l      l      l      l      l - l      l      l      l      l - l      l      l      l      l        Exp Date:

All self-paying patients will receive a standard HCFA insurance submission form for insurance purposes.

Doctor or Lab to be billed:

Street Address:

City, State+Zip or Country:

Phone: Fax:

lV. Specimen Information: (circle one) Blood       CSF       Bone Marrow              Other (specify) ____________

Date Collected: Required                                                                               Phleb

V. ICD-9 Code(s): Required (systemic complaint and/or diagnosis) 1)                   2)                   3)                  4)

VI. Tests:  Please check test or tests requested (next line)

 ____1100 HHV-6 DNA nested PCR

Shipping Instructions: FedEx is our preferred shipper. Ship Monday through Thursday using the "PRIORITY OVERNIGHT- NEXT BUSINESS MORNING" shipping option.   

Ship to:

Phone: 414.774.8612

For Lab Use Only: Rec'd                                                                         Acc #:                                                                        Mailer