Microbiology Requisition Form

Mail Results to:county( ) -FaX #patientaddResscitynaMezip codestateyRd ayMoFeMaleMaledate oF BiRtHcounty(last)tissue (speciFy)Wound (site)Fluid (speciFy)otHeR (speciFy)tHRoatnasopHaRynGealdate BeGun:MotiMe oF daysMeaRcultuReOTHER (SPECIFY)date sent to stateMod ayyRMod ayyRtiMeoF day:aMpMpMaMHaVe speciMens FRoM tHis patient Been suBMitted pReViously?yesnoseRuMstooltReatMentsuBMi tteR( ) -aRea code & pHone #d ayyRdatecollecteddateoF onsetPLEASE ATTACH YOUR TEST RESULTS :date coMpleteddRuGs used(FiRst)(Mi)naMe oF peRson coMpletinG tHis FoRMpHone #( ) -suBMitteR's laB nuMBeR:speciMen suBMitted is:MiXed isolateoRiGinal MateRialpuRe isolateMICROBIOLOGY clinicianclinician's pHone #( ) -city, state, zip code:speciMen inFoRMationLABORATORY EXAMINATION REQUESTED:d ayMoyRd ayMoyRplease print clearlycHaRt oR patient id nuMBeRMoleculaR diaGnosis/ pcRsinGle caseoutBReaKsuspected souRce oF inFection:speciMen is FRoMtRaVel HistoRy (continue tRaVel HistoRy in coMMents, iF necessaRy)FoReiGntocontactcaRRieRd ayMoyRd ayMoyRtod ayMoyRd ayMoyRFoR pHl use onlydate/time Receivedlab numberATTENTION.

Reference Bacteriology DOH 13-175 Nose and Throat Specimens DOH 305-003 Do NOT use this form to submit specimens to the Rabies, Water Bacteriology, Food Bacteriology,

Tags:

  Form, Microbiology, Requisition, Bacteriology, Microbiology requisition form

Information

Related search queries