04/09/2013 07:45 7028705311 THE VACCINE CENTER PAGE 05/08

04/09/2013 6:15:20 AM FROM: LABCORP LCLS BULK TO: 7028705311 LABCORP Page 2 of 5
TO: Th~ Vaccine Center

LabCorp Pho~ni.x
3930 E WatkiM Suite 300
Phoenix AZ 85034- 7251 Phone· 602-4S4~8000
I I
L:lballlltor)' I'PQr• nc ITI'Ir

Spocillie!!NU111ber
094.-195-1327-0
Patieoti...&N=
ParleotiD C:ot~ttol Nlllnbet
CF8.27321550
Accoum Number
27321550 I
AccoUDl Add"''s
Account Pboll!' ~ulnbtlr
702-870-1911 IR\>u(•
00
SMITll The vaccine Center
ClAVIN
Ji'~qont ~Ill Nam~
I J?;Jtioa! M;ddle N•me

1:\>ta)Volumo 500 E Windmill Lane ste 115

Patiooc SS#
I 702-540-9626 Potieot ptro.,.

SOA Fastlog
LAS VEGAS NV 89123
Ago (Y/MID)
44/07/00 I 09/04/68 I
Date clllirtb

Pllti"'\ Add"'"
M No
Addltloa.U lQ.(onnation
307 s:r:oux cT SRC: URINE
BOULDER CITY NV 89005

Dare ond Tiu\o Co!~ced

Q4/04/13 oo:oo
I Da(~;Entorod
0.4/05/13
I D•(e aod T.iill• Kopcmo
0~/09/13 06:14E~
:Pcysio:iaQ Nilllle
I NPI
I Pl:lyoiciwiD
BAKTARI,J
Tests Oro«•d
~R+Ct/GC NAA+H~sAg+HSV2(Iq.,,; HCV Antibocty
l 'I!I!!S~S ~SUL'Il ;FLAG UJil"tTS R~I'EREN'CI!: lN'l:~lVAL IJUI I
RPR+Ct/GC NAA+HBsAg+aSV2(Ig •••
BBsAg scre!i!n Negative Negative 01
RPR ·Non Reactive Non :Reactive 01
HIV 1/0/2 Abs-ICMA 01
HIV l/0/2 Abs-Inde~ Value <1. 00 <1. 00 01
Index Value: Specimen reactivity relative to the negative cutoff.
HIV l/0/2 Abs, Qual 'Non Reactive Non Reactive 01
Chlamydia t:rachomatis, NAA ' Negative Negative 01
Neisseria gono~rhoeae, NAA ,Negative Negative 01
Please note: 01
Acceptable specimens for this test are male urethral swab,
endocervical swab and liquid based pap specimens, vaginal swabs in
APTIMA transports and first void urine. see online Directory of
services for test number for rectal and pharyngeal specimens.
HSV 2 !gG, Type Spec <:0.91 index 0.00- 0.90 02
Negative <:0.91
Equivocal 0.91 - 1.09
Positive ~1.09

Note: Negative indicates no antibodies detected to

Hsv-2. Equivocal may suggest early infection. If
clinically appropriate, retest at later date. Positive
indicates antibodies detected to RSV-2; coinfeation
with HSV-1 cannot be excluded without type specific
tasting.
HCV Antibody
Hep C Virus Ab <0.1 s/co ratio 0.0 - 0.9 01
Negative: < 0.8
Indeterminate o.a - 0.9
Positiva: > 0.9

In ordsr to reduce the incidence of a false positive

~esult, the CDC recommends that all a/co ratios
between 1.0 and 10.9 be confipmed with ~dditional

I SMITH, GAVIN 094-195-1327-0 Seq#0719 I

04/09/13 06%14 ET FINAL REPORT Page 1 of 2
Tbis d<lCmn~nt contains priva~ and <:<:m!J.dentlal ))ea)th mfonuation pr¢l.«:led by state and federal law. ()2004-13 Labor:otoxy Cajp<lrstion of Amc&a ® Haldlngs
Jfyoubave rece~ved thia doomnentm orror, ple~se c@ 888-522-2677 All l_<igl:lts R~sernd
DOC! Ve-r: 1.49
04/0S/2013 07:45 7028705311 THE VACCINE CENTER PAGE 05/08
04109/2013 6:15:20 AM FROM: LABCORP LCLS BULK TO: 7028705311 LABCORP Pe~ge 3 of 5
TO: The Vaccine Center

LabCorp Phoerux
3930 E Watkins Suite 300
• ~"'1' ~ra1 "'"' ~~ Pho~ ~85034 - 7251 Phone· 602-454-8000
P1tle11tN= Sp~monNtllllbtf
SMITH, GAVIN
A.cl:oull! NUmber
27321550
I P•~omiO I Control N~.~mb~t
CFS.27321550
J Datnad Time CoDectod'
Oo:l/04/13 00:00
I Dare R!l!orlod
04/0~/13
Sex
M
094-195.;...1327-0
J44/07/oO I 09/04/oe
Az•(YIMID) Dol• o~ Bdrth

MSUL:r : l"t..ILG tmus

RIBA or PCR testing.

Ol PD :ta.bCor~;> :Phoenix Oir: Franlc ~yan, PhO

3930 ~ watkin5 Suite 300, PhQenix, A~ S5034-72Sl
02 BN LabCorp :!Ourlington Dir! William F Hancock, MD
1447 York Court, ~urlington, NC 27115-3361
~or inquiries, the physician ma.y contact aranch: 888-522-2677 Lab: 602-454~8000

SMITH, GAVlN 094-195-1327-0

04/09/13 06:14 ET FINAL REPORT Page 2 of 2
This document contains pllV~te and confidonti.•l b•aHl:) lnfonnation pro~ted by state and fodetallaw. ®:ZO(lil.-13 Laboratozy Corporation ilf AmW-ca <$1 Holdings
J:f you have =~iv..d th:\s docum~nt in CIIW, p)ea~ call 8SS-5:U-2677 All Right>; R~serwd
DOCl Vu: 1.49
 04/09/2013 07:45 7028705311 THE VACCINE CENTER
"~''""' .......................... ~~ .......,..-.. -· PAGE 07/08
OFa.:
~LabCorp
lhe Uscrine Center
OCall 0800.15
~ labQ<aloly Corporatloo ol Am"i~ .
§00 E Windmill Lant Stt 115 OMail
lAS UEGtS MD 8912;
·o find the nearest patient 102-010-1911' NVU
ervice center. visit www.
~bcorp.com or call 888-
ABCOF!P (888-522·2677).

· ·· ···········Group#··
· ·-"-· ....... -------· ~~-- .............. lniurQnc·~--,;;;iCires8

· -·-······--·~··-·····---·· 'j'Noo;e·Oi-in~~red Person

IRelatlc•n•M:i~ ................. " ...................... :·Retati~ns~lP'IO-~~~i~;;i ........ ..

Reier to Determining Necessity ot ABN Completion on reverse .
...........,.Employ~r Name
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Pf amf f!T
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v. .. k.~z,l.-s t.~:r Ab'i . v. .
~~~~~ ~~~~

Creatinine
gt 9?xin (Lano)dn")
Estradiol
Ferntln
FSHandLH
GGi

Glucose ...Sefl.lm 92947

hCG,_BI~SJoolli\ 0m1 (~rum Pm~l .B47o~.
et.taSubu,nil, Quen~ 84!0,2.
tJOL, Cholesterol.
 04/09/2013 07:45 7028705311 THE VACCINE CENTER PAGE 08/08

THE
VACCINE CENTER
And Travel Medicine Clinic

Consent for Sexually Transmitted Disease Testing

I, GaJ 1N s fV\ \,. -rt-1 (PRINT NAME:}, hereby request and authorize The Vaccine
Center (TVCTM) physicians and/or its medical staff, and/or the other health care providers ! have seen or will see to
collect blood/urine sample for analysis of:

'j( HIV "':k Herpes

*
:k Gonorrhea Hepatitis B

~ Chlamydia )k Hepatitis c

)t Syphilis

1understand and agree that these records will be disclosed and/or re-disclosed to The Vaccine Center staff and myself.
understand that in the event 1 test positive to HIV, Gonorrhea, Chlamydia and/or Syphilis, The Vaccine Center and Travel
Medicine Clinic (and all other clinics) are mandated by Nevada State Law to report the results to the Southern Nevada
Health District.

DISCLAIMER: Your test results show current and active infections only. It is recommended to repeat tests in 3 weeks
and 3-6 months if you are at risk from a recent exposure. Incubation period for HIV: 3 months, Syphilis: 1-3 months,
Herpe" 6-26 JkB. Chlamydia' 1-3 week;, Gonorrheo: 2-3 da!f.', Hepatais B' 1-5 months, Hepatttis c, 2-6 months.

INITIAL HERE I understand that payment today does not cover the cost of consultation with a clinician or
treatment. I understand that if I would like to meet with a clinician before or after testing that
the cost is $65 per visit.
COPIES: I have been advised that I am entitled to receive a copy of this Authorization.

Patient's PRINTED Name: _G_,...:....A.,;_\J~lNc__::__~-<)..:::..._fY\..,;....:.....1:.....l_:__:_(~~------

Patient's Date of Birth: _S.:...:(~f_(___lf~1--~-1-CJ!._:k~~-=--------
Patient's Social Securtty~ber:. @1o I~ 1£:
Patient's Signature: --Jb,.~"---~--J-~~--_,;;;:::::___________
Y~,_J~....:..0::-...'....--13..L___--~--
Today's Date: --'-1'1---'--"-lf....;....a_=--.._ _

Witness PRINTED Name:

Witness Signature ,

Today'sDate' #1/!J
0
r J4.t.Ckl Q
,1 ).. 't\.{!_/t.,[>
~~ n815:0

Main Office: Phone: 702.870.1911 Northwest Location:

500 E Windmill Lane, Suite 115 Fax: 702.870.5311 2051 N Rainbow Boulevard, Suite 100
Las Vegas, Nevada 89123 INWW. vaccineoenter.com Las Vegas, Nevada 89108
Appointments & Walk-ins Available [email protected] Appointments & Walk-ins Available