ARMIN LABS INDIVIDUAL TESTS ORDER FORM Last and first name of patient:
Send results to: Myself □ My physician □
BARCODE (Lab use only) Male □
Name of Practitioner and Clinic:
Female □
Date of birth (DD/MM/YY): House name/number:
Time and date of blood draw (DD/MM):
Address:
House name/number: Address:
Material/Quantity City:
Postcode:
Tel no:
CPDA □
Heparin □ City:
EDTA □
Serum □
Email:
Postcode:
Tel no: Email:
See overleaf for list of tests. Once the relevant tests have been selected, please do the following: Please enter the tests (numbers) you wish to order: _____________________________________________________________________ Please calculate the total amount to be paid for the tests: Add £30 for FedEx courier delivery: Total: If you would like to pay by bank transfer, please use the following details: Bank: A/C name: Sort code: IBAN:
Barclays Bank, 28 Chesterton Road, Cambridge CB4 3EZ, UK Academy Of Nutritional Medicine (AONM) 20-17-22 Account number: 63880265 GB02 BARC 2017 2263 8802 65 SWIFT/BIC: BARCGB22
If you would like to pay by credit card, please call the AONM helpline to make the payment. Once the payment is confirmed, AONM will send you an authorisation code by email, or give it to you over the phone. Please insert it in the box below: AONM Authorisation Code
Data Protection. Consent to data transfer and discharge from the duty of (medical) confidentiality. I hereby give my consent for my personal data and treatment data to be collected, stored, processed and used. I also agree that my data, which are necessary for invoice processing (e.g. name, date of birth, address, date of treatment, service codes, invoice sums, treatment documentation) will be disclosed to "Academy of Nutritional Medicine (AONM), St. John's Innovation Centre, Cowley Road, Cambridge CB4 0WS" and “ArminLabs, Zirbelstrasse 58. 2nd floor, 86154 Augsburg, Germany for the purpose of the creation of invoices or for collection of receivables or – if necessary – for judicial enforcement. This declaration of consent can be revoked at any time with effect for the future. In this respect I release my treating practitioner, AONM and ArminLabs and their employees from their obligation of (medical) secrecy. I also agree that the laboratory results, which are obtained within the scope of this laboratory order, will be disclosed to my treating practitioner.
Please sign below to say that you agree with the above: Date, signature: _______________________________________________________
Academy of Nutritional Medicine (AONM) St. John's Innovation Centre, Cowley Road, Cambridge, CB4 0WS Tel: 03331 210 305 Email:
[email protected]
Armin Labs Tests Please call 03331 210 305 to enquire about additional tests if needed. Test #
Description of test
□1 □2
Borrelia Elispot CD3/CD57+ cells
CPDA
□3 □4 □5 □6 □7A □7B □8 □9
Borrelia IgG/IgM ELISA Borrelia IgG/IgM Seraspot Borrelia DNA PCR Ehrlichia/Anaplasma Elispot Anaplasma IgM/IgG antibodies Ehrlichia IgM/IgG antibodies Ehrlichia/Anaplasma DNA PCR Bartonella IgG antibodies (henselae + quintana) Bartonella Henselae Elispot Bartonella IgM antibodies (henselae + quintana) Bartonella DNA PCR Babesia IgG/IgM antibodies Babesia microti Elispot Babesia DNA PCR Babesia DNA FISH Chlamydia pneumoniae Elispot Chlamydia pneumoniae IgG/IgA antibodies Chlamydia trachomatis Elispot Chlamydia trachomatis IgG/IgA antibodies Mycoplasma pneumoniae IgG/IgA antibodies Mycoplasma pneumoniae Elispot
Serum Serum EDTA CPDA Serum Serum
Hep+EDTA
Price
Test # Description of test
£166 £116
□41 □42 □43 □44 □45
ENA screening c- and p-ANCA CRP Diarrhoea/Coeliac Disease Organ profile: FBC, AST, ALT, GGT, LDH,CHE, total bilirubin, amylase, lipase, CK, creatinine, uric acid, sodium, potassium, alkaline phosphatase, TSH □46 Total protein, protein electrophoresis □47 Lipid profile (cholesterol, triglycerides, HDL, LDL) □48 Thyroid hormones (TSH, fT3, fT4) □49 Thyroid antibodies (TPO abs, TG Abs, TSH receptor Abs) □50 Parvovirus B19 IgG/IgM antibodies □51 Vitamin D □52 Vitamin B6 □53 Vitamin B12 □54 Folate □55 LipoDens Lipoproteins □56 C-6 ELISA □57 Borrelia myamotoi Elispot □58 Coxiella Burnetti antibodies □59 Malaria - proof of antigen □60 Salmonella antibodies (Widal) □61 Reverse T3 □63 Hormone Analysis - Estrogen □64 Hormone Analysis - Testosterone □65 Hormone Analysis - DHEA □66 Hormone Analysis - Progesterone □67 Hormone Analysis Dihydrotestosterone (DHT) □69 Dengue Virus IgG/IgM antibodies □70 Candida IgG/IgA/IgM antibodies □70A Candida albicans Elispot □72 Aspergillus antibodies □72A Aspergillus Peptide Mix 1&2 Elispot
Price Serum Serum Serum Serum Serum, EDTA
£165 £46 £16 £83 £67
Serum Serum
£18 £13
Serum Serum
£59 £114
Serum Serum EDTA Serum Serum Serum Serum CPDA Serum EDTA Serum Serum Serum Serum Serum Serum Serum
£46 £38 £45 £20 £20 £141 £40 £76 £161 £19 £109 £45 £28 £28 £28 £28 £28
Serum Serum CPDA Serum CPDA
£49 £96 £76 £28 £153
Serum
£55 £126 £134 £76 £80 £80 £157 £80
CPDA Serum
£76 £80
EDTA Serum CPDA EDTA CPDA Serum
£157 £80 £76 £157 £236 £76 £55
CPDA Serum
£76 £55
Serum
£55
CPDA
£76
Serum CPDA Serum Serum
£55 £76 £55 £80
Serum
£80
EDTA CPDA
£157 £121
Serum
£85
□73
Coxiella IgG/IgM antibodies (Q Fever)
Serum
£69
□28A
Toxoplasma IgG/IgM antibodies Yersinia Elispot Yersinia IgG/IgA antibodies Rickettsia IgG antibodies (conorii + mooseri) Rickettsia IgM antibodies (conorii + mooseri) Rickettsia DNA PCR EBV Elispot (2 antigens: lytic + latent) EBV IgG/IgM + anti-EBNA antibodies HSV 1/2 IgG/IgA/IgM antibodies
Serum
£76
□74
£103
HSV 1/2 Elispot
CPDA
£76
□29 □30 □31 □31A □32 □33 □34 □35 □36 □37 □38 □39 □40
CMV Elispot CMV IgG/IgM antibodies VZV IgG/IgA/IgM antibodies Varicella Zoster Virus Elispot VZV DNA PCR Coxsackie IgG /IgA antibodies HHV 6 IgG/IgM antibodies HHV 6 DNA PCR HHV 8 IgG antibodies HHV 8 DNA PCR CCP antibodies ANA ds-DNS antibodies
CPDA Serum Serum CPDA EDTA Serum Serum EDTA Serum EDTA Serum Serum Serum
£76 £57 £76 £76 £68 £57 £71 £157 £40 £157 £35 £23 £24
Tickplex Basic - IgG/IgM antibodies (Borrelia) Tickplex Plus - IgG/IgM antibodies (Borrelia, Bartonella, Babesia, Ehrlichia, Coxsackie, EBV, Parvovirus B19, Mycoplasma, Rickettsia) Panel A Standard Virus Panel Panel B Extended Virus Panel Panel C+ Comp. Bacteria Panel Echovirus IgG/IgM antibodies Zonulin antibodies TNF Alpha antibodies Interleukin 6 antibodies Interleukin 2 Receptor antibodies Botin (Vitamin H)
Serum
□28B
Serum
£533
See Panel order form for more details
£355 £566 £920 £57 £59 £35 £38 £59 £38
□9A □10 □11 □12 □12A □13 □14 □15 □16 □17 □18 □19 □19A □20 □21 □22 □23 □24 □25 □26 □27
Tel: 03331 210 305
2 x EDTA
2 x EDTA
□75
□77 □78 □79 □86 □87 □88 □89 □90 □91 □
Academy of Nutritional Medicine (AONM) St. John's Innovation Centre, Cowley Road, Cambridge, CB4 0WS
Serum Serum Serum Serum Serum Serum
Email:
[email protected]
