Your provider has requested that you complete a Litholink ...

[Pages:4] 800 338 4333 (M?F, 7:30am?6:00pm CT)

WDeelacroLmitehtooliLnitkhoPlaintike.nLti:tholink is a laboratory that specializes in 24-hour urine testing for kidney stone formers. Your provider has requested that you complete a Litholink At-Home kit. Your provider is waiting on these test

rWeseulcltosmineotrodeyrotuorsLtaitrht oyoliunrkkKididnenyeystSontoentreeaPtrmeveennt tpiolann.Program. Your doctor has chosen Litholink

because our laboratory offers the highest quality kidney stone prevention services available. Please make sure to read the instructions and verify your supplies before starting your At-Home kit.

IPmlpeoarstaentnRoetmei:nydoerus:will be required to repeat your collection if these instructions

are not followed:

? If you were given a test request form/lab order for your Litholink At-Home kit, you will need

?

Ytreoosuruerlttcuiornnllyeiotcuitnriostnhaemmbpuolesxst wbbieetihnagytorlueerjaecscottme2dp2laehntodeudhrausvrilinonenggst,aobmrueptpleensao.t

Fltoahnielugereenrtttiorhearepntrou2cr6nesthhsoisaugrfsoa.rinm.

may If your

? Yporouvimdeursftacxeodllethcet atellsot freyqouuersutrfionremdourrilnabg othrdeercodilrleeccttliyonto. Litholink we will have it on file.

?? YYoouurr csoalmlecptleionismeuxsttrebme ealtyletiamste2s2enhsoiutrisvelo;nwgh, ebnutynooulfionngisehr tyhoaunr 2c6olhleocutrsio.n you

? Ymousmt usshtipcoyloleucrtuarlilnoef syoaumrpulreinseafmore2d4ahyoourrsn.ext business d.ay.

?? DDoo nnoott rreeffrrigigeerarateteyoyuoruurruinrein. e. Use the urine preservative at the start of your

collection.

?

?

DTohroaennpgoretesjlueegtrvasatttoitvoheel (cstohtanerttlaiqomuf iiydno,auutrencctoahlpleepcectdoiolblneoctttlieo,nancdonctaapi)nmeru.st be dropped into the large

?? YDoounmotalyetosntloyotl ackoentVamitainmatine yCouurputroine10c0olmlegctdioanily. Anything over 100mg must

be stopped five days prior to starting your collection, unless otherwise ? iSntsotprutackteindgbVyityaomuinr pCh(ypsiilcl fiaornm. , vitamins, and/or supplements) that is greater than 100

mg per day 5 days prior to the start of your At-Home kit. Vitamin C occurring in foods and drinks can be ingested as normal. If you have questions about your collection process, call us at 800 338 4333 and select

o?ptioYnou3r. sYaomu pmleayisaelsxotrveismiteloyutrimweebsseitnesaittivwew; wyo.luithmoulisntk.schoimp yaonudr sseanmdpalen(ys)emthaeilsianmqueiroiersnext to inbcfouo@sllielnitcehtsoioslinndkwa.ycilol(mMbe.onre-Sjeactt)e. dA.ny sample received after 96 hours from the start of the

FSoinr cmeorreelyi,nformation, FAQs or to contact us visit or email at LitholinkInquiry@ Litholink Patient Care Team

Verify that you have received all necessary collection materials. Keep the Patient Sample

Shipping Box; it will be used for returning your samples.

1 collection container per specimen

1 Collection Aid Included for females

L5a5b8_9C5_oLrpA_BC-oWlleocrtkioinng_FFoilrem_.pin1d.idndd1 1

1 greentopped 50 ml tube per specimen

1 tube of liquid urine preservative per specimen

Collection Data Form

All information must be filled out completely and returned with your sample(s).

Patient Information LAST NAME:

DATE OF BIRTH:

HEIGHT:

IN

CM

SEX: (CIRCLE ONE)

MALE

FEMALE

ADDRESS:

CITY:

HOME PHONE: (

)

PRESCRIBING PHYSICIAN'S LAST NAME:

PRESCRIBING PHYSICIAN'S OFFICE PHONE: (

)

FIRST NAME: PARENT/GUARDIAN NAME: WEIGHT: (CIRCLE ONE)

STATE:

WORK PHONE: (

)

FIRST NAME:

MI:

LBS

KG

ZIP CODE: EXT:

Collection 1 START TIME:

Collection 2 (if necessary)

AM

COLLECTION 2 START TIME MUST MATCH COLLECTION 1 STOP TIME

STOP TIME:

AM

START TIME:

AM

DATE COLLECTION ENDED:

/

/

STOP TIME:

AM

TOTAL VOLUME:*

ML

DATE COLLECTION ENDED:

/

/

TOTAL VOLUME:*

ML

*TOTAL VOLUME EQUALS TOTAL AMOUNT OF URINE IN COLLECTION CONTAINER.

Collection Check List

Did you collect for a full 24-hour period? (Your urine must be collected for at least 22 hours but no more than 26 hours ? per collection)

I will ship my samples today or next business day.

Have you included the Test Request Form the doctor gave you and your collection data and insurance forms in the Litholink shipping box?

Have you allowed at least 10 days between the date you completed your collection and your scheduled doctor's appointment?

If you have answered "No" to any of these questions, or have any concerns regarding your collection, call 800 338 4333, Monday ? Friday, 7:30am ? 6:00pm CST, and ask to speak to a Patient Care Representative.

800 338 4333 (M?F, 7:30am?6:00pm CST)

6/11 LLK0003

From:

Order:012345

000100010001

Phone: (555) 555 5555

To:

LITHOLINK CORP: 2230 WEST CAMPBELL PARK DR. CHICAGO, IL 60612 (312) 243-0600

Forms ? Collection Data Form ? Insurance Information Form

1 pre-paid FedEx mailing form

1 biohazard bag with absorbent paper

PaSthieipnpt inSgam Bopxle

:e

P PlePaasttoeieolnifpttehne. re

1 Litholink Patient Sample Shipping Box

1/17 LLK0003

77/2/22//1136 19::1255 PAMM

Collection Instructions

Do not record any information on this sheet, please use the Collection Data form.

Collection 1

1

2

3

Collection 1

START TIME:

PLE

EXAM

Helpful Hint: Schedule your Fed-Ex pick-up for the day you plan to finish your collection(s). See shipping Instructions #6.

When you wake up in the morning, flush your first urine in the toilet.

This is the START TIME.

Record this time on the Collection Data Form where it says START TIME.

Open the tube of urine preservative and empty it into the collection container.

Handle preservative with care and keep out of reach of children.

4

5

6

7

Collection 1

START TIME: STOP TIME:

EXAMPLE

DATE COLLECTION ENDED:

2500

2400 2300 2200 2100

2000

1900 1800 1700 1600

1500

1400 1300 1200

Drop the urine preservative tube and lid into the collection container. This ensures every drop of the preservative gets into the container.

*Do not place urine in the refrigerator at any time.

Collect all ooff yyoouurr uurrine iintoo the coonnttaaiinneerr oovveerrtthheenneexxtt 24 hours, iinncclluuddininggthaenyvery ufirisnteucrionleletchte dfodlluorwinigngthe nmigohrntinagndanthdaatnfiyrsutriunreinceololefcttheed fdoullroinwgintghemnoirgnhint.g.

This is the STOP TTIIMMEE.. For women who may havee trouble uurriinnaattiinngg ddiirreeccttllyy into tthhee ccoollleeccttioionnccoonnta- inetar,inpelar,cpelathcee cthoelleccotilolencatiiodn oaviderotvheer ttohielettoailnedt athnedn pthoeunr tphoeuur rtihnee uinritnoethineto cthoelleccotliloenctcioonntcaoinnetra. iner.

Record the STOP TIME on the Collection Data Form where it says STOP TIME.

Record the date you finished the collection on the Collection Data Form where it says "DATE COLLECTION ENDED".

Place the collection container on a flat surface and use the measuring tool along the side of the container to read how much fluid is inside the container.

This is the TOTAL VOLUME.

57043_LAB_A_LLK0003_p2.indd 1

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Collection Instructions (CONTINUED)

8

9

Collection 1

START TIME:

PLE

EXAM STOP TIME:

DATE COLLECTION ENDED:

TOTAL VOLUME:

10

11

Record this TOTAL VOLUME on the #OLLECTION $ATA form where it says "TOTAL VOLUME".

Sehcaukreetlhideacnodlleschtaiokne the colnletactinioenr.container.

Fill the green-topped tube

Twist top tightly to seal.

marked Collection 1 about

3/4 full with the urine sample.

)F YOU HAVE BEEN INSTRUCTED TO DO TWO

HOUR COLLECTIONS lLL THE SECOND GREEN TOPPED TUBE MARKED #OLLECTION ABOUT FULL FROM THE SECOND COLLECTION CONTAINER

12

Collection 2

1

2 Repeat

Collection 2

START TIME:

PLE

EXAM

Flush thee rreemmaaiinniinngguurriinnee.

Danodndoitsdciasrcdarcdotllheectpiorenservcaotnivtaeinbeotr.tle or cap into the toilet. The jug, preservative

bottle and cap can be dis-

carded into the trash.

If you have been instructed to complete two 24-hour collections, continue with the instructions for Collection 2, otherwise skip to the shipping instructions.

The START TIME of the second collection is the same as the STOP TIME of the first collection.

Record the START TIME of the second sample on the #OLLECTION $ATA &ORM.

Repeat steps from Collection 1 starting at number 3.

57043_LAB_A_LLK0003_p3.indd 1

1/5/17 7:00 AM

Blood Draw Instructions

If Serum is not checked off on your Test Request Form, please go to the shipping instructions below.

Blood Draw

1a

2

Instructions

Blood draw must be completed the morning your entire collection has ended.

Patient Service Center

Alternate Blood Draw Location

1b

1a) Find your local Patient Service Center at or by calling 1-888-Labcorp (1-888522-2677) for your blood draw or call Litholink at 1-800-338-4333.

1b) Follow your physician's instructions on where to go for your blood draw.

Shipping Instructions

WATER IS OK

Do not eat or drink 8 hours before having your blood drawn (water is OK).

3

Patient Test Forms Litholink Patient Information PacketTM

Test Request Form Litholink Kidney Stone Prevention Program

w(w8(wM 0.0l?i)tFh,3o73l:i38n0k4a.3cmo3m ?36:00pm CST)



Bring all materials to the blood draw location. They will mail the blood and urine samples out together. (Instructions for the nurse can be found on the orange sticker inside the box).

1

2

Place the green-topped tube(s) in the biohazard bag with the absorbent paper and seal the bag.

Test Request Form Litholink Kidney Stone Prevention Program



Litholink Patient Information PacketTM Patient Test Forms

((wM8w0?wF0,.)7li3t:h33o08lain4mk3?.3c6o3:0m0pm CST)

Enclose the following into your Litholink Patient Sample Shipping Box:

1) SSeeaaleleddbbioiohhaazazradrdbabgag with filled

2) Cgoremepnl-ettoepdpCeodllteucbtieo(ns)Data and

2) ICnsoumrapnlecteeIdnfCoromlleactitoinonFoDramtsa and

3) 3)

TgTIneievsssetutnrRaRteoneqcqyueoueuesInstbftFyooFrtmrohmeram/tdiO/oorOcndtreoFdrroe?rrmi?fsif

given to you by the doctor

* Do not return orange jugs back to

3

4

Litholink.

Complete the return address portion on the right-hand side of the FedEx form.

Peel the backing off the back of the FedEx form and stick the form to the top of the box.

5

6

Remove the adhesive strip under the front flap of the Litholink Patient Sample Shipping Box and seal.

Call 1-800-GO FEDEX (1-800-463-3339) and press "0", then say "ship a package" to schedule a pickup.

57043_LAB_A_LLK0003_p4.indd 1

1/5/17 8:26 AM

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