Quantitative Analysis of Adalimumab (Humira®) and Anti-Adalimumab Antibodies (LS-163) PRESCRIBER INFORMATION PATIENT INFORMATION Last Name: Last Name: First Name: First Name: Clinic: Sex: F M Address: Date of Birth: yyyy / mm / dd No Street Office Reference Number: City Prov. Postal code Tel: Health Insurance No.: (RAMQ, OHIP, etc.) Fax: Licence No. yyyy/mm/dd Signature: X Date SAMPLE COLLECTION TYPE OF SPECIMEN Serum: 1 mL DATE: ________/________/________ For optimal results, sample collection should be within 24-48 hours prior to the next Humira injection. Year Month Day RESULTS TRANSMISSION Results will be provided within 10 to 15 working days. Please note that the prescriber can elect to access patient results online. To request web access, please contact our customer service department. GD Specialized Diagnostics 3885 Industriel Blvd., Laval, Quebec, H7L 4S3 Tel: (450) 901-3071 / 1-888-988-1888 • Fax: (450) 663-4428 E-mail:
[email protected] • Website: www.gamma-dynacare.com FOR INTERNAL USE ONLY Comments: __________________________________________________________________________ __________________________________________________________________________ This analysis is supported by an unrestricted grant provided by Abbvie. Rev. 2014SE30 PATIENT INSTRUCTIONS ONTARIO / QUEBEC For sample collecon, please go to the nearest Gamma‐Dynacare Paent Services Centre (no appointment required). For a list of locaons and hours, go to www.gamma‐dynacare.com or call 1‐888‐988‐1888. MANITOBA For sample collecon, please call (204) 944‐0757 ext. 7253 to make an appointment at the following Gamma‐Dynacare Paent Services Centre: 830 King Edward St., #100, Winnipeg, MB, R3H 0P4. SASKATCHEWAN For sample collecon, please go to one of the following Gamma‐Dynacare Paent Services Centres, from Monday to Friday (no appointment required): Saskatoon – 39‐23rd St East, #5, Saskatoon, SK S7K 0H6, tel: (306) 655‐4030 Regina – 2723 Avonhurst Dr, Regina, SK S4R 3J3, tel: (306) 766‐6977 ALBERTA Sample collecon centres are located throughout the province.