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QUEST DIAGNOSTICS TITER REQUISITION ORDER FORM Name SSN Street Address City State Zip Daytime Phone Number Email Address If not a Chicago student what is your regional site Name of Test Cost of Test Rubella Titer 11. 00 Rubeola Measles Titer 17. 00 Mumps Titer Varicella Titer Amount Enclosed 16. 50 Hepatitis B Surface Antibody only request this test if you have already finished the 3 vaccine Hepatitis B series 13. 50 Blood Drawing Charge 15. 00 TOTAL AMOUNT ENCLOSED Money order or cashier s check only payable to UIC College of Nursing NO CASH OR PERSONAL CHECKS PLEASE Please return this form with payment to UIC College of Nursing Attn Immunity Records Room 138 845 S* Damen Ave. 00 Rubeola Measles Titer 17. 00 Mumps Titer Varicella Titer Amount Enclosed 16. 50 Hepatitis B Surface Antibody only request this test if you have already finished the 3 vaccine Hepatitis B series 13. 50 Blood Drawing Charge 15. 00 TOTAL AMOUNT ENCLOSED Money order or cashier s check only payable to UIC College of Nursing NO CASH OR PERSONAL CHECKS PLEASE Please return this form with payment to UIC College of Nursing Attn Immunity Records Room 138 845 S* Damen Ave. .

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