Herbivores in the sahara desert

ITEM 06458: FRONT: PRINTS BLACK: REVISED 25 AUGUST 2008Client consent(To be signed in the presence of a Sullivan Nicolaides Pathology Collector.)I give consent for the tests requested to be performed. I understand that Medicare benefits do not apply to these tests. If the tests include HIV and/or HCV testing, I acknowledge that I have read and that I understand the policies of the insurance company to which the report will be sent. I acknowledge that the pathology laboratory may also have legally defined notification requirements associated with these tests.OFFICE USE ONLYSullivan Nicolaides Pathology Collector declarationVerification of identityClient’s signature:Name (please print):I declare that I have taken due and proper care to verify the identity of the patient by inspection of his/her:Passport Drivers licence Other photo identification (please specify):Date:Signature:Surname, Given name (including middle initials)Account addressTests requested (please
). Refer over for fasting instructions.Copy reports toReferred by (name, company, address)SexLaboratory numberDate of birthPhone (Home)Your referencePhone (Work)E/LFT(Code MB2)FBC(Code FBZ)Fasting Glucose (Code GLF)Other (please specify):Fasting Cholesterol HDL/LDL(Code CHDL)Hep B surface antigen(Code HEP)Hep B surface antibody(Code HEP)Hep C serology(Code HEP)HIV(Code INSHV)Cotinine(Code COT)Application/Policy/Claim numberClient declaration of consentThis declaration must be signed in the presence of a Sullivan Nicolaides Pathology Collector.Testing CANNOTproceed without the insurance company Application/Policy/Claim number.OFFICE USESSTTubeEDTATubeLIHTubeCITTubePPTTubeACDTubeVacuTube24hrUrine24hrAcidUrineRandUrineJarOtherFaecContHistoContPapSlideThPThinPrepChlamSwabTransRedSwabPlainBlackSwabCard FrozenUnspunPay catDate collected/––––––/–Time collected:Date received/––––––/–Time received:Patient fasting?YES NOPlace location stamp here. Internal reference only.FOR DATA ENTRYSeen by /Loc/CollNOT FOR DATA ENTRYStaff ID. I confirm patient ID correct.ITEM 06458 AUGUST 2008Commercial Testing ServicesInsurance requestMUSTbe completed IN FULL. Medicare benefits DO NOTapply.