Transcription of Test Request Form - ndhealth.gov
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Test Request Form - ndhealth.gov
Test Request Form fax 11 Patient Information *Name: (Last)*(First) (M) *Sex: Male FemaleRace/Ethnicity: *DOB (mm/dd/yyyy):Specimen Information *Collection Date:*Type/Source: Acute ConvalescentFacility Information *Facility Name:Address: *Phone:*Physician:*FacilityCode:Patient Data **Address: **City/County: **Phone: State&Zip: Hospitalization: Yes No Care Facility: Resident EmployeeSymptoms: Test Request MANDATORY REPORTABLE CONDITION Isolate: _____BACTERIOLOGY Aerobic Culture ID:_____ Anaerobic Culture ID:_____ Bordetella species HDA Carbapenem Resistance Gene Screen Gastrointestinal (GI) Panel Legionella Culture Rickettsia PCR BIOTERRORISM RULE OUT Agent Suspected: _____MYCOBACTERIOLOGY Mycobacteria Culture (TB) & smear Mycobacteria TB complex /RifampinScreen (Requires Culture & smear ) Mycobacteria Reference ID Quantiferon (TB)MYCOLOGY Fungal Culture Fungal Reference IDPARASITOLOGY Ova and Parasites Giemsa Thick & Thin Blood SmearsHEPATITIS Hepatitis A Antibody, IgM Hepatitis A, B & C Panel Hepatitis B & C Panel Hepatitis B Core Antibody, IgM H
Mycobacteria Culture (TB) & Smear Mycobacteria TB complex /Rifampin Screen (Requires Culture & Smear) Mycobacteria Reference ID Quantiferon (TB) MYCOLOGY Fungal Culture Fungal Reference ID PARASITOLOGY Ova and Parasites Giemsa Thick & Thin Blood Smears HEPATITIS Hepatitis A Antibody, IgM Hepatitis A, B & C Panel
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