FertilMARQ™ Package Insert - Embryotech Laboratories

TMFertilMARQ Home Diagnsotic Screening TestResults FormDCBATestWell DReferenceColor AReferenceColor CTestWell BFill out this form completely for each test. If you decide toconsult a physician after testing, you should bring this form.Name: _______________________________TEST 1:Date of First Test: ________________________Check appropriate box: Positive: Color in Test Well B is equal to or darker thanReference Color A. Negative: Color in Test Well B is lighter thanReference Color A.TEST 2:Date of Second Test: ______________________Check appropriate box: Positive: Color in Test Well D is equal to or darker thanReference Color C. Negative: Color in Test Well D is lighter thanReference Color C.Physicians: See note on reverse sidePage 19