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RED Laboratories - Request Form 08-10XMRVenDocument Transcript
TEST REQUEST FORM R.E.D. Laboratories N.V. Z.1 Researchpark 100 - 1731 Zellik Belgium XMRV testing BE 462 648 824 RPR BRUSSELFamily name: First name:Address:Zip Code: City: Country:Phone:Date of birth: Sex: Male / FemaleDate and hour blood drawn:Name of requesting physician: Your patient ref.:Shipping charges We may take care of the shipment of your samples from the point of collection to our laboratory. There are no shipping charges forsamples collected in Belgium. For samples collected in certain countries we ask for a contribution to the shipping costs. Contact us for more information. XMRV Detection of the Xenotropic Murine leukemia Related Virus in culture. 2 x 4 ml whole blood in EDTA tubes.□ XMRVc Includes detection of other MLV-related viruses by 340 € SPECIMEN MUST BE RECEIVED WITHIN 72H AT ROOM TEMPERATURE PCR 2 ml whole blood in EDTA tube. Stable for 72 hours.□ MLVp Detection of MLV-related viruses by PCR 108 € For longer periods freeze at –20°C or –80°C. Testing on other samples (sperm, sputum, biopsy…) is also possible, freeze at –20°C□ XMRVab Serology XMRV 219€ 1 serum separator tube (yellow cap)XMRV Test Information:The currently available XMRV test at R.E.D. laboratories is the life virus (co-culture) method. We use the same method which was published in the Lombardi et al. Octo-ber 2009 issue of Science. This work suggests that XMRV may be the underlying cause of ME/CFS but subsequent studies failed t o reproduce these results. More researchis needed to confirm the implication of XMRV in CFS and other disease. Please visit our website for more information.Negative Result: The virus is present at very low-copy numbers. A negative result may mean that at the time of the blood draw the virus was not infectious, the viral titerwas below the detection limit, or the virus may be present in other body tissues than in blood. Therefore, getting a negative result does not definitely mean that you are notinfected.Positive Result: RED laboratories do not make any claims regarding the biological significance, and medical implications, of a positive result . You must discuss withyour physician if you have questions regarding transmissibility, health implications, or treatment.Please note that the laboratory has no RIZIV number. These tests are «research only»; interpretation must be done by a health care professional. The cost for the requestedanalyses will be invoiced directly by R.E.D Laboratories to the patient, at the above mentionned rate. R.E.D Laboratories may possibly use blood samples for researchpurposes. Signature: Date: A signed copy of this form must be sent together with the samples.Phone: + 32 (0)2 481 53 10 (from 9 a.m to 4 p.m, Monday to Friday) Email: email@example.comFax: +32 (0)2 481 53 11 www.redlabs.com