CFRs Lyme Disease Test Kit Instructions

CENTRAL FLORIDA RESEARCH Instructions on collecting & packing specimens for shipping by FedEx Express

KIT CONTENTS
1 EDTA Tube
1 Styrofoam Box
1 Biohazard bag
1 Requisition
1 Kit Request Form
1 Biohazard Label

Test Descriptions

REQUISITION & PAYMENT
A licensed physician or nurse practitioner must order the test.
Complete and enclose Test Requisition.
Be sure to check the test(s) ordered
Complete credit card information.
Physician information and Patient Information must be complete. The requisition must be signed by the physician in the physician information at top of requisition and by the patient or responsible party at the bottom of the requisition .

REQUISITION
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 REQUISITIONPATIENT NAME: F M / / Last Name First Name MI Sex Date of Birth AgeSS# ADDRESS: Street City ST Zip CodeSPECIMEN SOURCE:Whole BloodCollected by:SerumDate: Time: TEST NAMETEST METHODACCESSION NUMBER:Borrelia burgdorferi Direct Fluorescent Antibody by Flow Cytometry DFADiagnosis:ImmunoDOT™Borrelia burgdorferi Screening TestEIA 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 CodeTelephone # ( ) - 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. Rev. 1/9/08 by pp, 2/12/08, 6/16/08, 10/02/08, 10/28/08, 3/24/10

Test Requisition Form

SPECIMEN COLLECTION
Clean the arm and top of tubes with PVP-Iodine or other anti-bacterial prep.
For Borrelia burgdorferi Immunodot Antibody Detection Screening Assay:
Collect 1 SST Gel Separator Tube, allow to clot.
Centrifuge for 10 minutes to separate the serum.
For Borrelia burgdorferi Direct Fluorescent Antibody Test with enumeration and Quantification by Flow Cytometry:
Collect 1 EDTA (Lavender Stopper) Tube and mix well by gently rocking the tube back and forth.

LABEL TUBES AND TAPE
Label tubes with patient’s Name, ID number (can be SSN, birthdate or Patient Account Number), Date, Time collected and Initial of phlebotomist.
Information on tubes must match requisition or specimen will be rejected.
Cut two 3 inch long strips of ¾ inch wide tape to secure the rubber stopper of each filled specimen tube. Use the first strip of tape over the top of the rubber stopper and down along opposite sides of the tube. Use the second strip of tape to wrap around the specimen tube and also cover the cut ends of the first strip of tape.

LABEL TUBES AND SECURELY TAPE

PACKING SPECIMEN FOR SHIPMENT
Place the tubes in the Styrofoam Container with the absorbent material and tape around the entire container. Put the Styrofoam Container in a biohazard bag.
Place the Biohazard Bag in a shipping container with the Requisition…

Packing Specimen

SHIPPING
Place a frozen ice pack (not included) in the FEDEX overnight shipping envelope or container.
The package must identify its contents as “Diagnostic Specimens”.
Ship specimens by overnight courier Monday through Thursday. The lab is closed on Saturday and Sunday.
Specimens must be received within 48 hours of collection.
SPECIMENS RECEIVED OVER 48 HOURS FROM COLLECTION MAY BE REJECTED.

PACKAGE CONTENTS + + + + = +

SHIPPING OUTSIDE OF U.S.A.
For all specimens shipped from outside the U S, please complete Shipping Specimen Invoice for Customs

Contact Us
Address:
342 E. Central Ave. Winter Haven, Florida 33880
CFR is open Monday - Friday from 8:30 a.m. - 4:00 p.m. EST (GMT -5:00) Phone Number: (863) 299-3232 Fax Number: (863) 299-3355
www.centralfloridaresearch.com

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CFRs Lyme Disease Test Kit Instructions

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