_____/_____/______
FRY LABORATORIES, L.L.C.-Requisition (Int)
LAB
15720 N. Greenway-Hayden Loop, Suite 3 Scottsdale, AZ 85260
BILL
NP
(866)927-8075 (480)656-4932 fax frylabs.com CLIA#03D1026968
LAB USE ONLY
Physician
Physician Name: _______________________________________________________
Facility / Address: ______________________________________________________
City: ________________________ State: ________ Zip: ______________
Patient
Phone: (____)__________________
Physician's Signature / Stamp
Fax: (____)__________________
Last Name: ________________________________________
First Name: _____________________________________
City: ______________________ State: _____ Zip: ______________ Gender:
Payment Information
!
Street Address: __________________________________________________
Payment
Source:
Payment
Method:
qPatient
v3.17i
Phone: (_____)_____________________
qmale qfemale
DOB: ____/____/_____
qReferring Laboratory
qPhysician qOther:____________
qCheck
qMaster Card qVISA
qDiscover qAmerican Express
Requisitions received without payment may be delayed
until payment is received.
Name On Card: ________________________________
Card Number: _________________________________
Expiration: __/__ Security Code: ____ Billing Zip: _____
Signature for Credit Card
Dx
!
ICD-10 Codes: _________
_________
Protozoal Profile (submit lavender)
Fluorescent DNA Stain (includes enrichment)
Pan-Eukaryotic (Protozoa/Fungi) DNA Analysis
Stained Blood Film Test (submit lavender)
Modified May-Grunwald (includes Giemsa)
Advanced Stain Test (submit lavender)
Fluorescent DNA Stain (includes enrichment)
Complete Stain Profile (submit lavender)
Modified May-Grunwald (includes Giemsa)
Fluorescent DNA Stain (includes enrichment)
Co-Infection Profile (submit tiger & lavender)
A*
$1545
_________
Collection Date: _____/______/______ Time: ___________
Bartonella Profile (submit tiger & lavender)
Bartonella quint./hens. IFA IgM/IgG
C
$405
D
$650
E
Co-Infection Plus Profile (submit tiger & lavender)
Individual Serology Tests (submit tiger)
$325
Q-Fever IFA IgM/IgG
$255
Babesia microti IFA IgM/IgG
Rickettsia rickettsii/typhi IFA IgM/IgG
$305
Bartonella quint./hens. IFA IgM/IgG
Toxoplasma gondii IFA IgM/IgG
$205
Babesia microti IFA IgM/IgG
$200
Modified May-Grunwald (includes Giemsa)
Bartonella quint./hens. IFA IgM/IgG
$280
Fluorescent DNA Stain (includes enrichment)
Ehrlichia chaffeensis IFA IgM/IgG
$200
Anaplasma phagocytophilum IFA IgM/IgG
$200
Anaplasma / Ehrlichia IFA IgM/IgG
$305
Ehrlichia chaffeensis IFA IgM/IgG
Borrelia Profile (submit lavender)
Fluorescent DNA Stain (includes enrichment)
Modified May-Grunwald Stain
Traditional Giemsa (included)
G
$800
H*
$1280
Pan-Bacterial (Bacteria/Archaea) DNA Analysis
Babesia Profile (submit tiger & lavender)
I*
Modified May-Grunwald (includes Giemsa)
Babesia microti IFA IgM/IgG
Pan-Eukaryotic (Protozoa/Fungi) DNA Analysis
Some tests use components that are for Research Use Only. Please
visit our website for more information about each assay.
Price
Lyme Western Blot IgM/IgG
Babesia microti IFA IgM/IgG
$650
$1350
Pan-Eukaryotic (Protozoa/Fungi) DNA Analysis
Anaplasma phagocytophilum IFA IgM/IgG
Modified May-Grunwald (includes Giemsa)
Ehrlichia chaffeensis IFA IgM/IgG
$1280
Pan-Bacterial (Bacteria/Archaea) DNA Analysis
$350
Molecular Diagnostics (submit lavender)
$1350
Pan-Bacterial (Bacteria/Archaea) DNA Analysis
B
Anaplasma phagocytophilum IFA IgM/IgG
Bartonella quint./hens. IFA IgM/IgG
F*
Modified May-Grunwald (includes Giemsa)
$1575
This requisition is for blood samples only. Please
submit non-blood samples using the appropriate
requisition and sample kit. Please note that
incomplete requisitions may result in the delay or
inability to complete the test order.