OUTPATIENT LABORATRY REQUISITION



OUTPATIENT LABORATORY REQUISITIONPlease bring this with you to the Registration desk. Please be prepared to provide current insurance information. Please see the back of this form for fasting and collection information. PATIENT LEGAL NAME:DATE OF BIRTH:COLLECTED DATE & TIMEA.M.P.M.MEDICAL NECESSITY – Physicians (or other individuals authorized by law to order tests) should only order tests that are necessary for the diagnosis or treatment of a patient rather that for screening purposes. Each test requires a diagnosis code or sign/symptoms or complaint. Some tests below have a diagnosis code listed that may be appropriate for your patient. For these tests, please indicate a diagnosis by checking a box or writing a numeric code or the patient’s sign/symptom/complaint.PANELS (See reverse for componets)URINE TESTSMICROBIOLOGY??Basic Metabolic Panel 1 PST??Creatinine Clearance 24 hour 24 U/ASource __________________________________________________???Comprehensive Metabolic Panel 1 PST ???Creatinine Serum Required 1PSTSusceptibility and organism ID reflex test performed when appropriate ??Electrolyte Panel 1 PST Required: Height ________ Weight ________ (additional charge)??Hepatic/Liver Function Panel 1 PST??Urinalysis, complete (UAM)??Culture, Aerobic w/Gram Stain ??Stool Culture??Hepatitis Panel, Acute 1 PST??AFB Culture and Smear ??Ova & Parasites Screen? Urine Culture - includes Colony Count??Anaerobic Culture ??Giardia Antigen, Stool??Lipid Panel, Fast 12hr 1 PST Dx Codes for Urine Culture??Blood Culture ??Clostridium Difficile Dx ??2720 Pure Hypercholesteremia?????????5990 Urinary Tract Infection NOS??Fungus Culture ??Fecal WBC??????2721 Hyperglyceridemia?????????7881 Dysuria ????Fungus Smear ??Rotavirus??????2724 Hyperlipidemia?????????Other _________________________??Influenzae A & B ?????Occult Blood??????4019 Hypertnesion???Pertussis Culture ??Chlamydia/GC, DNA Amp??????25000 DMII w/o comp, not uncontrolled??Other urine tests: ______________________?RSV ( Resp. Sync. Virus) ???Herpes Simplex Culture??????V58.61 Long term use of Meds NEC_________________________________________??Sputum Culture w/Gram Stain ??Culture w/o Gram Stain??????Other:___________________________________________________________________??Strep A Screen & Culture ??Strep A Culture ????OTHER: _________________________________________________??____________________________________________________________ OTHER BLOOD TESTS: PST = Green, SST = Gold, L = Lavender, BL = Blue, G = Gray, BLK = Black ? Albumin ??Alkaline Phosphatase ??ALT ? Amylase ? Antibody Screen (only) ? AST ? Bilirubin, Total ? Bilirubin, Direct ? BNP (Broin Natiuretic Peptide)? BUN ? C-Reactive Protein (CRP) ? Calcium ? CEA? CBC (includes Platelet Ct) ? CBC with Diff & Platelet Ct ? Chloride ? Cholesterol, Total ? Cortisol AM (draw before 10 am) ? Cortisol PM (draw after 4 pm) ? Creatinine ? Digoxin? Erythrocyte Sed Rate (ESR)? Estradiol ? Ferritin ? Folate Fast 6 Hr? FSH (Foll. Stim. Hormone) ? Gamma Glutamyl Transferase (GGT)? Glucose - Fasting? Glucose - Random Glucose Tolerance Testing- Fasting (see reverse)? Gestational 100 g, 3 hr G? Non-Gestational 75 g, 2 hr G? Group, Rh, Antibody Screen ? HCG Quantitative? HDL Cholesterol ???????????????????????? Hemoglobin and Hematocrit ? Hemoglobin A1c ? Hepatitis A Antibody (lgM) ? Hepatitis Bcore Antibody (total lgM/lgG) ? Hepatitis Bcore Antibody (lgM only) ? Hepatitis B surface Antibody ? Hepatitis B surface Antigen ? Hepatitis C Antibody ? Iron (draw before 10 am) ? Iron binding capacity (includes iron) ? LD (Lactate Dehydrogenase) ? LDL Cholesterol, measured - Fast 12 Hr ? LH (Luteinizing Hormone) ? Lipase ? Lithium? Magnesium ? Mononucleosis Screen? Phosphorus? Phenobarbitol? Phenytoin (Dilantin)? Phosphorus ? Platelet Count ? Potassium (K+) ? Pregnancy, Serum ? Prolactin ? PSA Annual Screen ? PSA Diagnostic ? PSA Total & Free ? PT/INR (Prothrombin Time ) ? PTT (Partial Thromboplastin) ? RA Screen ? Rubella Screen ? Sodium (Na+) ? Tegretol (Carbamazepine)? Testosterone Free ? Testosterone Total ? T3, Free ? T3, Total ? Free T4 ? Free T4? Thyroperoxidase Antibody (TPO Ab) ? TSH, Sensitive Thyroid Testing? Total Protein ? Transferrin ? Triglycerides - Fast 12 Hr? Uric Acid ? Valproic Acid (Depakote)? Vitamin B12 ? Vitamin D: 25-OH, Total (D2 + D3) (ViTD) Other tests Requested:__________________________________________________________________________________________________________________________________COPY REPORT TO: Results needed by: ? CALL RESULTS TO PHYSICIAN_________________________________________________________________________________________________________________ORDERED BY: DIAGNOSIS (Enter ICD-9 code and/or sign, symptom or complaint in your medical record for tests ordered) _________________________________________________________________________________________________________________ORDERING LOCATION:ORDERING LOCATION PHONE #__________________________________________________________________________________________________________________________________________________MD 17 2014PATIENT INFORMATION REGARDINGSCHEDULED TESTSYour Physician will indicate which of the following directions (if any) apply to the test he has ordered for you.??Lipid Panel ? HDL Cholesterol??Triglycerides ? LDL CholesterolFasting 12-14 hoursDo not eat or drink anything for 12-14 hours before your test. Water may be taken as you desire, but this is the only exception. Do not drink coffee, tea, juice or soft drinks. Please bring this order form to the Registration area before visiting the laboratory.??GlucoseFasting 8 hoursDo not eat or drink anything for 8 hours before your test. Water may be taken as you desire, but this is the only exception. Do not drink coffee, tea, juice or soft drinks. Please bring this order form to the Registration area before visiting the laboratory.??Glucose Tolerance TestThree day diet preparation with an 8 hour Fasting prior to testa. For 3 days prior to the test, eat at least 150 grams of carbohydrate per day along with your meals.b. You are not to eat anything for 8 hours before the test.. Water may be taken as you desire but this is the only exception. DO NOT drink coffee, tea, juice, or soft drinks.c. Please plan to arrive so as to allow sufficient time to register and complete sample collections during laboratory hours of service. Please bring this order form to the Registration area before visiting the laboratory.d. In the laboratory, you will be given a solution of glucose (sugar) to drink. The test consists of drawing several blood samples. The test usually takes about 3 hours for pregnant patients and 2 hours for non-pregnant patients. Please plan to remain in the laboratory vicinity throughout the testing period.??24 Hour Urine collection(Specimen container available from the lab)a. At 7:00 a.m. empty the bladder. Do not save this specimen but discard in the toilet.b. Collect all urine voided after 7:00 a.m. and add urine to the specimen container.c. Keep the container in a cool place during collection.d. At 7:00 a.m. on the next day empty the bladder and add this final urine to the specimen container.e. Return the container to the Laboratory as soon as possible. Keep container cool during transport. Please bring this order form to the Registration area before visiting the laboratory.PANEL COMPONENTSElectrolytes: Sodium, Potassium, Chloride, Total CO2Basic Metabolic: Electrolytes, BUN, Creatinine, Calcium, GlucoseComprehensive: Basic Metabolic Panel, Albumin, Alk Phosphatase, ALT, AST, Bilirubin (total), Total ProteinHepatic/Liver Function: Bilirubin (Total & direct), Albumin, Alk Phosphatase, AST, ALT, Total ProteinHepatitis Acute: Hep A Antibody, Hep Bs Antigen, Hep Bcore Antibody (IgM), HCVHepatitis Chronic: Hep Bs Antigen & Antibody, Hep Bcore Antibody (IgM/IgG), HCVLipid: Cholesterol Total, HDL Cholesterol, Triglycerides, Calculated LDL & VLDL, and management guidelinesMD 17 2014 ................
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