NOS3 Testing for Omega-3 Processing To Be Completed by Clinic To Be Completed by Patient HEALTH CARE PROVIDER INFORMATION PATIENT INFORMATION ____________________________________________________ LAST NAME HEALTHCARE PROVIDER NAME (print clearly) ____________________________________________________ FIRST NAME CLINIC NAME ___________________________________________________ DATE OF BIRTH (DD/MONTH/YY) ADDRESS  MALE  FEMALE ________________________________________________________ CITY PROVINCE POSTAL CODE (___)___________________ PHONE NUMBER (___)______________________ FAX NUMBER _______________________________________________________ SIGNATURE SPECIMEN COLLECTION DATE: _______________________ (DD/MONTH/YY) For Laboratory Use Only ____________________ PROVIDER #  NOS3 G894T (rs1799983) INSTRUCTIONS: 1) 2) 3) 4) NOTE: HCP signature and provider # are required Complete this test request form. Complete the patient label on specimen bag. Complete payment information. Insert sealed specimen bag and this form into the pre-addressed padded envelope (follow Cheek Cell Collection Instructions to collect the sample). 5) Seal envelope and mail in regular post. PAYMENT INFORMATION Total Cost of the test is $100.00 CAD  VISA  MASTERCARD  Cheque enclosed ( Payable to Bay Area Genetic Laboratory) Card Number _____ Expiration date _____________________________________________________________________ Card holder name (as it appears on card) I agree to comply with the card holder agreement and authorize Bay Area Genetic Laboratory to bill this credit card. ______________________________________________________________________________ Patient signature (required) Date (dd/month/yyyy) Bay Area Genetic Laboratory  565 Sanatorium Road  Suite 205B, Sir William Osler Bldg  Hamilton, ON L9C 7N4  www.bagl.ca Phone: 905-385-1045  FAX: 905-385-1025 [email protected]