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MEDICAL DIAGNOSTIC LABORATORIES, 2439 Kuser Road Hamilton, NJ 08690-3303. (609) 570-1000 Fax (609) 245-7665. Toll Free (877) 269-0090. Core OB/GYN Test Requisition Form Ordering Physician/Laboratory Pathology Test Selection (Required: Include the ordering physician's first & last name, NPI, practice name, complete Date Collected (Required): Specimen Source: address, phone number and fax number.). Anatomic Source (Required): Cervix/Endocervix Vagina Vaginal Cuff Other: _____. Date of LMP: Previous Results: ASCUS CIN 1 Other: Normal LGSIL CIN 2. Date of Last Pap: Reactive HGSIL CIN 3. Pathology Test Requisition with completed clinical Information must accompany specimen ThinPrep . Liquid Pap only Liquid Pap with HPV Options Ages 21 and older Ages 30 and older 1301 Liquid 1302 1301 with Reflex HPV if 1304 1301 with Pap test ASCUS or greater HPV.

*Reflex to antibiotic resistance by Molecular Analysis. ♦Reflex to metronidazole resistance by Real-Time PCR.** Reflex to azithromycin resistance by Pyrosequencing. Ψ Reflex to azithromycin & fluoroquinolone resistance.

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