UMass Memorial Health Care
5829300-655320 Do Not Use This Space00 Do Not Use This SpacePRINT, APPLY LABEL OR STAMP: DO NOT ABBREVIATE ONLY ONE TEST PER SUBMISSION FORM Submitting Facility (Receives Test Result): _UMASS-Marlborough Hospital_____________________Facility / Laboratory Name (required)__157 Union St_________________Street Address__Marlborough, MA 01752_______________City, State Zip___508-486-5489________508-229-1240____________Phone # Secure Fax #:2. Patient Info:________________________________________Last Name, First Name________________________________________Street Address________________________________________City, State Zip________________________________________Patient ID: Phone #:4. Sex: M F Other DOB:_________5. Race: (Check One)American Indian or Alaska Native AsianBlack or African American WhiteNative Hawaiian or Pacific Islander OtherOrdering Clinician/ Phone# (required):______________________________________________Clinician Name (First and Last Name) Phone number#6. Ethnicity: Hispanic or Latino Non-Hispanic or LatinoTest Requested: Collection Date: Date of Onset:_____COVID-19_________________________________________________(required) One Per Form (required) One Per Form (required)SerologyCultureAcuteContactTest of CureDate of Culture: ConfirmationSurveillanceDate of Subculture:ConvalescentSymptomaticSample Treated Y N If yes, how: Source of Specimen: (required) One Per FormAnal canalNasopharynxStoolBody Fluid (site)BloodPlasmaThroat (pharynx)Bronchus (site)Bone MarrowSerumUrethraExudates (site)CervixSpinal FluidUrineWound (site)GastricSputumTissue (site)Other: (Specify)Additional Patient Information:Symptoms, and DurationTravel History (Dates and Locations)Animal / Insect contact: (specify)Relevant Immunizations (Dates)Previous Laboratory ResultsPlease fill out “Additional Patient Information” section on front of form for the following tests:AdenovirusHerpesRickettsiaArbovirus testingInfluenzaRespiratory Synctial virus (RSV)BabesiaLymphocytic choriomeningitis virus (LCM)RubellaCampylobacterLegionellaSalmonellaChikungunyaLyme DiseaseShigellaCytomegalovirus (CMV)MeaslesSt. Louis EncephalitisDengue FeverMumpsSyphilisE. coliMycoplasma pneumoniaeVaccinia virusEastern Equine EncephalitisParainfluenzaVaricella zosterEnterovirusParasitology serologyVibrioEhrlichiaPertussisWest Nile VirusHantavirusQ FeverYellow Fever ................
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