Cml Allergen Test Requisition

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Allergen Test Requisition
MM
DD
YYYY
Service Date:
Patient Information
LAB USE ONLY
PLACE BAR CODE LABEL HERE
Last Name
First Name
Home Phone
Apt/Suite/Address
City/Province/Postal Code
/
/
MM
DD
YYYY
M/F
OHIP
Version Code
Sex
Date of Birth
Physician Information
/
/
MM
DD
YYYY
X
Name
Clinician/Practitioner Number
Signature
Date
Apt/Suite/Address
City/Province/Postal Code
Phone
Fax
Please “X“ the required allergen
LAB USE ONLY
PLACE TESTS LIST LABEL HERE
NOTE: Mixes may be used as a screen. If results are positive, individual allergens can be
requested on the same sample up to four weeks after specimen collection. For further
information please call CML HealthCare Client Services at 1-800-263-0801

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