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.

Signature: X yyyy/mm/dd

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. To ﬁnd a locaon near you, please call 1‐888‐988‐1888.

BRITISH‐COLUMBIA / NEW BRUNSWICK / NOVA SCOTIA / P.E.I. / NEWFOUNDLAND

Please refer to our home collecon services described below.

HOME COLLECTION SERVICES ACROSS CANADA

GD Specialized Diagnoscs oﬀers home collecon services across Canada. A trained professional will come to your home to perform the blood draw and will then ship the sample to our laboratory.

Contact our Customer Service Department at 1‐888‐988‐1888 to make an appointment.

For more informaon or for any quesons, please contact our Customer Service Department at 1‐888‐988‐1888.