Imprimer
Paris, 2013/06/19
Dear colleague,
Please find below:
- a typical prescription for FibroTest (HCV, HBV)
- a typical prescription for FibroMax (for hepatitis, alcohol and metabolism)
Our teams are available to you for any additional information, especially for possible assistance in interpreting the results of our tests.
Sincerely,
Dr Mona Munteanu
Bioperdictive Medical Director
Physician ___________
Location ______________, Date ___ / ___ / _____
Last Name : _________________________
First name : _________________________
Birth Date : ____ / ____ / ______
Sex : [ ] Female / [ ] Male
NOT Fasting
1. Assays
- Haptoglobin
- Alpha2-Macroglobulin
(not to be confused with beta2-microglobulin) - GGT
- Bilirubin
- Apolipoprotein A1
- ALT
2. FibroTest : Not reimbursed
Physician's signature
Physician ___________
Location ______________, Date ___ / ___ / _____
Last Name : _________________________
First name : _________________________
Birth Date : ____ / ____ / ______
Sex : [ ] Female / [ ] Male
Weight : _____ kg Height : _____ m
Requires fasting Do not forget to write weight, height, sex and birthdate of patient.
1. Assays
- Haptoglobin
- Alpha2-Macroglobulin
(not to be confused with beta2-microglobulin) - GGT
- Bilirubin
- Apolipoprotein A1
- ALT
- AST
- Blood Glucose (Fasting)
- Triglycerids
- Total Cholesterol
2. FibroMax : Not reimbursed
Physician's signature