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Screening ID:
100001 |
Randomization ID:
123456 |
Accession ID:
888888 |
Initials:
AAA |
DOB:
12-Nov-1973 |
Gender:
Male |
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Mailing Address:
1234 Main Street, New Hope, MN 55428-3623 |
Phone:
763-404-1443 |
Fax:
763-553-9796 |
Email:
abccompany@somewhere.com |
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Fax Confirmation |
Date |
Time |
Successful? |
Fax # |
Sender |
18-Dec-2007 |
9:06:00 |
Y |
763-553-9796 |
Shelly Smith |
17-Dec-2007 |
9:31:00 |
N |
763-555-9999 |
Shelly Smith |
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Critical Information |
Visit 1 |
Test |
Reference Range
(Low - High) |
Value |
Units |
Albumin |
3.5 - 5.5 |
2.2 |
g/dL |
ALT |
10 - 25 |
9 |
U/L |
AST |
10 - 25 |
9 |
U/L |
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Fax information to:
James Walker by Monday, December 17, 2007 at: 763-489-6111 |
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