Ua_allergie_engl_ohnepreis

Submission form
Business Hours: Mo - Fr: 8:00 - 19:00 h, Sa: 9:00 - 13:00 h First name _______________________________________ Zipcode/City:_______________________________________ Date of Birth: ______________________________ Ultrashort History - PLEASE ALWAYS FILL OUT !!! Location:
__________________________________________ _______________________________________________________ Detailed General History - DOG / CAT / HORSEWhich food is fed: ________________________________________________________________________________________________________________ Onset of symptoms:____________________________ (y Symptoms - Skin:
________________________________________________________________________________________________________________ Previous tests - Skin:
________________________________________________________________________________________________________________ Symptoms – Lungs:
________________________________________________________________________________________________________________ Previous tests - Lungs:
________________________________________________________________________________________________________________ Symptoms – GI tract:
________________________________________________________________________________________________________________ Previous tests - GI tract:
________________________________________________________________________________________________________________ Previous Therapy
Sample material: A=swab, AM=abort mat., AS=ascites, BS=blood smear, CP=citrat-plasma, EB=EDTA-blood, EP=EDTA-plasma, F= feather, FA=faeces, Gw=tissue, H=urine, HA=hairs, HP=heparin-plasma, HS=urinary stones, HT=skin, K=scurf, KM=bone marrow L=liver, LQ=liquor, Ln=lymph node, M=spleen, MH=morning urine, N=kidney, NaFB=natrium-fluorid-blood, D000130140033D NaFP=natrium-fluorid-plasma, NSP=nasal lavage, S=serum, SV=synovia, TA=order spec. swab, V=vomit, Z=tick, *=partnerlab 7105 Screening Test
(mites, pollen, moulds, flea saliva)
Please differentiate any positive reaction of the Screening Test automatically.
Main tests
7106 Seasonal Panel
7107 Perennial Panel
7116 Feathers/hairs/epithelia
(cat, dog, rabbit, guineapig, parrot, duck, goose) 7130 Insect Panel
(simulium, culex, tabanus, stomoxys calcitrans, cockroach) 7124 Hymenoptera Panel
7122 Mediterranean Panel
(grasses, weeds, tree pollen, moulds, mites, flea saliva) 7108 Sensitest
(IgE and IgG of 16 commonly used food ingredients) 7125 Food-allergens-extended
(IgE and IgG of horse, ostrich, venison, rabbit, wild boar, reindeer, amaranth, sorghum) 7127 Chinese Panel
(grasses, weeds, tree pollen, moulds, mites, flea saliva, insects, malassezia) Further tests
7117 Malassezia (IgE)
Sarcoptes (IgG)
Staphylococcus (IgG)
Flea saliva (IgE)
8032 MDR1 gene defect / Ivermectin sensitivity*
Allergen-specific Immunotherapy (ASIT, Hyposensitization) 1
Starter Set ASIT
Refill ASIT
This order is valid as a veterinarian prescription. Delivery time: 3-4 weeks. Date:
Signature veterinarian:
7105 Screening Test
(mites, pollen, moulds, flea saliva)
Please differentiate any positive reaction of the Screening Test automatically.
Main tests
7106 Seasonal Panel
7107 Perennial Panel
7116 Feathers/hairs/epithelia
(cat, dog, rabbit, guineapig, parrot, duck, goose) 7130 Insect Panel
(simulium, culex, tabanus, stomoxys calcitrans, cockroach) 7122 Mediterranean Panel
(grasses, weeds, tree pollen, moulds, mites, flea saliva) 7108 Sensitest
(IgE and IgG of 16 commonly used food ingredients) 7125 Food-allergens-extended
(IgE and IgG of horse, ostrich, venison, rabbit, wild boar, reindeer, amaranth, sorghum) 6103 Flea saliva
Allergen-specific Immunotherapy (ASIT, Hyposensitization) 1
Starter Set ASIT
Refill ASIT
This order is valid as a veterinarian prescription. Delivery time: 3-4 weeks. Date:
Signature veterinarian:
7105 Screening Test
(mites, pollen, moulds, insects)
Please differentiate any positive reaction of the Screening Test automatically.
If no Screening Test has been requested we suggest you test for both seasonal and perennial
allergens as a clinical differentiation is often not possible.
Main tests
7106 Seasonal Panel
7107 Perennial Panel
7116 Feathers/hairs/epithelia
(cat, dog, rabbit, guineapig, parrot, duck, goose) 7110 Insect Panel
(simulium, culex, tabanus, musca, culicoides) 6108 Food Panel
(IgE and IgG of wheat, barley, oats, corn, molasse, soy, yeast, alfalfa) Allergen-specific Immunotherapy (ASIT, Hyposensitization) 1
Starter Set ASIT
Refill ASIT
This order is valid as a veterinarian prescription. Delivery time: 3-4 weeks. Date:
Signature veterinarian:
1 It is also possible to order an allergen - specific immunotherapy (ASIT) based on your intradermal skin test result for most countries.
Please send a prescription in case of an order. Delivery time approx. 3-4 weeks.
Please feel free to call in case of any questions.
Supply reguests:
General Business Conditions:
All prices in Euro ex. VAT / All statements according to our conditions, See www.laboklin.com / All terms and prices are subject to
changes.
013.014 12/04

Source: http://www.laboklin.fi/uploaded_files/Laboklin-allergiatestilomake.pdf