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How to get the SARS-CoV-2 Antibody Test Panel1. Have this requisition signed by your physician.2. Provide sample.3. Get your results on Dynacare Plus.

For more details visit dynacare.ca/covid19-antibody-test

Medical Record No.:

Surname, First Name:

Phone:

Phone:

For laboratory use only Date received (yyyy/mm/dd):

OHIP/CPSO/Prof. License No:

Address:

Other Health Care Provider:

Postal code:

Postal code:

Fax:

Fax:

Address:

Postal code: Patient Phone No.:

Surname: First Name:Middle Name:(optional)

Date of Birth (yyyy/mm/dd):

Name of clinic/ facility/health unit:

Sex: M F

Specimen Type: SerumContainer: SGTVolume: 2.00 mLCollection Requirements: CentrifugeStorage and Transport: Store and ship refrigerated

Test Preparation Instructions: It is recommended that SARS-CoV-2 Antibody testing not be performed until at least 14 days post symptom onset or following exposure to individuals with confirmed COVID-19. False negative results may occur if the specimen is collected too soon following infection or is collected from immunocompromised patients. If the patient is symptomatic, consider testing with a molecular COVID-19 test.

Lab Instructions: Specimen processing for Ontario samples at Brampton laboratory. 115 Midair Court, Brampton ON. L6T 5M3.

CONFIDENTIAL WHEN COMPLETEDThe personal health infomation is collected under the authority of the Personal Health lnformation Protection Act, s.36(1)(c)(iii) for the purpose of clinical laboratory testing. If you have questions about the collection of this Personal Health Information, please contact Dynacare Customer Care at 800.565.5721.

1. Submitter Lab Number (if applicable)

Ordering Clinician (required)

Surname, First Name:

OHIP/CPSO/Prof. License No:

Name of clinic/ facility/health unit:

Address:

SARS-CoV-2 Antibody Test Panel RequisitionALL Sections of this form must be completed.

Test Fee (Antibody Panel): $80 | Test Fee (Travel Test): $75 To be paid upon sample collection.

2.Patient Information

Health Card No.:

Physician Signature:

Affix requisition label, here.

Province:

3. Test(s) Requested

Specimen Collection Date (yyyy/mm/dd):

Specimen Collection Time:

(required)

4.Specimen Type:

Serum

SARS-COV-2 Antibody PanelOMNI Order Code: COV2AB; Panel Test Code: CVABIncludes Total Nucleocapsid Qualitative & Total Spike Quantitative Antibody tests Can be used for natural exposure and/or post-vaccine.

SARS-COV-2 Antibody Test for TravelTest Code: ZCOV For travel only.