Microbiology Test Request - mayocliniclabs.com

1 Page 1 of 4T244 MC0767rev0220 Microbiology Test RequestClient Information (required)Client NameClient Account PhoneClient Order CodeReportable Disease Information Complete information as indicated by your state requirementsClient NameClient Account PhoneClient Order Street AddressCityStateZip CodeCountyRace/EthnicityHome PhoneSpecimen Type Venous CapillaryParent/Guardian Name (Last, First)Patient Information (required)Patient ID (Medical Record No.)Patient Name (Last, First, Middle)Gender Male FemaleBirth Date (Month DD, YYYY)Collection Date (Month DD, YYYY)Time s Street AddressPhoneCityStateZip CodeVisit for the most up-to-date test and shipping specimens to: Mayo Clinic Laboratories 3050 Superior Drive NW Rochester, MN 55901 Customer Service: 855-516-8404 Billing Information An itemized invoice will be sent each month. Payment terms are net 30 the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US) 2020 Mayo Foundation for Medical Education and Research I hereby confirm that informed consent has been signed by an individual legally authorized to do so and is on file with this office or the individual s provider s office.

2 Signature _____Note: It is the client s responsibility to maintain documentation of the order. Reason for Referral (required)ICD-10 Diagnosis CodeNote: It is the client s responsibility to maintain documentation of the order. New York State Patients: Informed Consent for Genetic TestingSubmitting Provider/Provider Name Information (required)Submitting/Referring Provider (Last, First)Fill in only if Call Back is ( ) _____ _____Fax * ( ) _____ _____Provider s National (NPI)*Fax number given must be from a fax machine that complies with applicable HIPAA 2 of 4T244 MC0767rev0220 PARVPP arvovirus B19, Molecular Detection, PCR, Plasma PARVOP arvovirus B19, Molecular Detection, PCR, Varies PNRPP neumocystis jiroveci, Molecular Detection, PCR, Varies RESLRR espiratory Pathogen Panel, PCR, Varies RESPMR espiratory Pathogen Panel, PCR, Nasopharyngeal STFRPS higa Toxin, Molecular Detection, PCR, Feces TKPNLTick-Borne Panel, Molecular Detection, PCR, Blood PTOXT oxoplasma gondii, Molecular Detection, PCR, Varies TOXBT oxoplasma gondii, Molecular Detection, PCR, Blood WHIPBT ropheryma whipplei, Molecular Detection, PCR, Blood TWRPT ropheryma whipplei, Molecular Detection, PCR, Varies URRPU reaplasma species, Molecular Detection, PCR, Varies VRERPV ancomycin-Resistant Enterococcus, Molecular Detection, PCR, Varies LVZVV aricella-Zoster Virus, Molecular Detection, PCR, Varies LCWNVWest Nile Virus, Molecular Dectection, PCR, Spinal Fluid WNVPWest Nile Virus (WNV)

3 , Molecular Detection, PCR, Plasma RZIKSZika Virus, PCR, Molecular Detection, Serum RZIKUZika Virus, PCR, Molecular Detection, Random, UrineSPECIMEN CULTURES (RAW SPECIMEN)Bacterial Cultures GENSB acterial Culture, Aerobic with Antimicrobial Susceptibilities, Varies ANAESB acterial Culture, Anaerobic with Antimicrobial Susceptibilities, Varies CFRCSB acterial Culture, Cystic Fibrosis with Antimicrobial Susceptibilities, Varies LEGIL egionella Culture, Varies HELISH elicobacter pylori Culture withAntimicrobial Susceptibilities, VariesFungal Cultures FBLF ungal Culture, Blood FDERMF ungal Culture, Dermal FGENF ungal Culture, Routine FVAGF ungal Culture, Vaginal FSFungal Smear, VariesPatient Information (required)Patient ID (Medical Record No.)Client Account No. Patient Name (Last, First, Middle)Client Order Date (Month DD, YYYY)MOLECULAR DIAGNOSTICS LADVA denovirus, Molecular Detection, PCR, Varies LCADPA denovirus, Molecular Detection, PCR, Plasma LBABB abesia species, Molecular Detection, PCR, Blood PFGEB acterial Typing by Pulsed-Field Gel Electrophoresis, Varies BTWGSB acterial Typing by Whole Genome Sequencing, Varies BARTBB artonella, Molecular Detection, PCR, Blood BARRPB artonella, Molecular Detection, PCR, Varies LCBKPBK Virus, Molecular Detection, PCR, Plasma LCBKBK Virus, Molecular Detection, PCR, Random, Urine QBKBK Virus, Molecular Detection, Quantitative, PCR, Plasma QBKUBK Virus, Molecular Detection, Quantitative, PCR, Urine BPRPB ordetella pertussis and Bordetella parapertussis, Molecular Detection, PCR, Varies BMIYBB orrelia miyamotoi Detection PCR, Blood BMIYCB orrelia miyamotoi Detection PCR, Spinal Fluid BRBPSB road Range Bacterial PCR and Sequencing, Varies CHIKSC hikungunya Virus, PCR, Molecular Detection, Serum CHIKCC hikungunya Virus, PCR, Molecular Detection.

4 Spinal Fluid CDFRPC lostridioides (Clostridium) difficile Toxin, Molecular Detection, PCR, Feces CIMRPC occidioides immitis/posadasii, Molecular Detection, PCR, Varies CBBRPC oxiella burnetii (Q Fever), Molecular Detection, PCR, Blood CBSRPC oxiella burnetii (Q Fever), Molecular Detection, PCR, Serum CBRPC oxiella burnetii (Q fever), Molecular Detection, PCR, Varies CMVNGC ytomegalovirus (CMV) Drug Resistance, Next-Generation Sequencing, Plasma CMVQNC ytomegalovirus (CMV) DNA Detection and Quantification by Real-Time PCR, Plasma LCMVC ytomegalovirus (CMV), Molecular Detection, PCR, Varies DENGSD engue Virus, Molecular Detection, PCR, Serum DENGCD engue Virus, Molecular Detection, PCR, Spinal Fluid EHRLE hrlichia/Anaplasma, Molecular Detection, PCR, Blood ENTPE nterovirus, Molecular Detection, PCR, Plasma LENTE nterovirus, Molecular Detection, PCR, Varies LEBVE pstein-Barr Virus (EBV), Molecular Detection, PCR, Varies EBVQUE pstein-Barr Virus DNA Detection and Quantification, Plasma GIPG astrointestinal Pathogen Panel, PCR, Feces GNRGGram-Negative Bacillus Antimicrobial Resistance Genes, PCR Panel, Varies HERPBH erpes Simplex Virus 1 and 2, Qualitative PCR, Blood HERPVH erpes Simplex Virus 1 and 2, Qualitative PCR, Varies HSVCH erpes Simplex Virus (HSV), Molecular Detection, PCR, Spinal Fluid HBRPH istoplasma capsulatum/Blastomyces species, Molecular Detection, PCR, Varies HHV6 Human Herpesvirus-6, Molecular Detection, PCR, Plasma HHV6 VHuman Herpesvirus-6, Molecular Detection, PCR, Spinal Fluid FLUMSI nfluenza Virus Type A and Type B, and Respiratory Syncytial Virus (RSV), Molecular, PCR, Varies FLUNPI nfluenza Virus Type A and Type B, and Respiratory Syncytial Virus (RSV), Molecular, PCR, Nasopharyngeal Swab LCJCJC Virus, Molecular Detection, PCR, Spinal Fluid KKRPK ingella kingae, Molecular Detection, PCR, Varies KNSRPKPC (blaKPC) and NDM (blaNDM)

5 Surveillance, PCR, Varies LEGRPL egionella species, Molecular Detection, PCR, Varies PBORBLyme Disease, Molecular Detection, PCR, Blood PBORRLyme Disease, Molecular Detection, PCR, Varies LCMALM alaria, Molecular Detection, PCR, Varies CSFMEM eningitis/Encephalitis Pathogen Panel, PCR, Spinal Fluid LCMSPM icrosporidia species, Molecular Detection, PCR, Varies MTBRPM ycobacterium tuberculosis Complex, Molecular Detection, PCR, Varies MTBXPM ycobacterium tuberculosis, Complex, Molecular Detection, PCR, Sputum MGRPM ycoplasma genitalium, Molecular Detection, PCR, Varies MHRPM ycoplasma hominis, Molecular Detection, PCR, Varies MPRPM ycoplasma pneumoniae, Molecular Detection, PCR, VariesPage 3 of 4T244 MC0767rev0220 Patient Information (required)Patient ID (Medical Record No.)Client Account No. Patient Name (Last, First, Middle)Client Order Date (Month DD, YYYY)Mycobacterial Cultures SAFBAcid-Fast Smear for Mycobacterium, Varies TBIDSC ulture Referred for Identification, Mycobacterium and Nocardia with Antimicrobial Susceptibility Testing, Varies CTBM ycobacteria and Nocardia Culture, Varies CTBBLM ycobacterial Culture, BloodViral Cultures VIRNRV iral Culture, Non-Respiratory, Varies VRESPV iral Culture, RespiratoryISOLATED ORGANISM REFERRED FOR IDENTIFICATIONAll of the following information must be submitted to obtain identification of any organism mediumRecovery mediumExtent of identificationDate collectedSuspect Brucella, Fancisella, B.

6 Pseudomallei, B. anthracis, Y. pestis? Yes NoDescription (Gram reaction, Morphology, tests performed) FUNIDC ulture Referred for Identification, Fungus CTBIDC ulture Referred for Identification, Mycobacterium and Nocardia, Varies TBIDSC ulture Referred for Identification, Mycobacterium and Nocardia with Antimicrobial Susceptibility Testing, Varies IDENTO rganism Referred for Identification, Aerobic Bacteria ANIDEO rganism Referred for Identification, Anearobic BacteriaANTIMICROBIAL SUSCEPTIBILITYI dentification of organism submitted: MMLRGA ntimicrobial Susceptibility, Acid-Fast Bacilli, Rapidly Growing, Varies MMLSGA ntimicrobial Susceptibility, Acid-Fast Bacilli, Slowly Growing, Varies ZMMLSA ntimicrobial Susceptibility, Aerobic Bacteria, MIC, Varies MMLSAA ntimicrobial Susceptibility, Anaerobic Bacteria, MIC, Varies TB1 LNAntimicrobial Susceptibility, Mycobacterium tuberculosis Complex, First Line, Varies MMLNSA ntimicrobial Susceptibility, Nocardia species, Varies MMLYPA ntimicrobial Susceptibility Panel, Yeast, Varies CARNPC arbapenemase Detection-Carba NP Test, Varies KPNRPKPC (blaKPC) and NDM (blaNDM) in Gram-Negative Bacilli, Molecular Detection, PCR, Varies MTBPZM ycobacterium tuberculosis Complex, Pyrazinamide Resistance by pncA DNA Sequencing, Varies OXVRPOXA-48-like (blaOXA-48-like) and VIM (blaVIM) in Gram-Negative Bacilli, Molecular Detection, PCR, Varies OVSRPOXA-48-like (blaOXA-48-like) and VIM (blaVIM)

7 Surveillance, PCR, Varies TBNGSM ycobacterium tuberculosis Complex, Molecular Detection of Drug Resistance Markers, Whole Genome Sequencing, Varies TBPZAS usceptibility, Mycobacterium tuberculosis Complex, Pyrazinamide, Varies TB2 LNSusceptibility, Mycobacterium tuberculosis Complex, Second Line, Varies VRERPV ancomycin-Resistant Enterococcus, Molecular Detection, PCR, VariesDIRECT AND SPECIAL EXAMINATION ACARPA canthamoeba species Molecular Detection, PCR, Ocular FLARPFree-Living Amebae, Molecular Detection, PCR, Varies SFUNG1,3-Beta-D-Glucan (Fungitell), Serum GSBVGram Stain for Bacterial Vaginosis HPSAH elicobacter pylori Antigen, Feces UBTUBT Helicobacter pylori Breath Test SHPVH uman Papillomavirus (HPV) DNA Detection with Genotyping, High-Risk Types by PCR, SurePath, Varies HPVH uman Papillomavirus (HPV) DNA Detection with Genotyping, High-Risk Types by PCR, ThinPrep, Varies LAGUL egionella Antigen, Urine SSF1 Nocardia Stain, Varies SPNP neumocystis Smear, Varies QF T4 QuantiFERON-TB Gold Plus, Blood ROTAR otavirus Antigen, FecesCHLAMYDIA TRACHOMATIS, NEISSERIA GONARRHOEAE, AND TRICHOMONAS VAGINALIS CGRNAC hlamydia trachomatis and Neisseria gonorrhoeae by Nucleic Acid Amplification (HOLOGIC), Varies CTRNAC hlamydia trachomatis by Nucleic Acid Amplification (HOLOGIC), Varies GCRNAN eisseria gonorrhoeae by Nucleic Acid Amplification (HOLOGIC)

8 , Varies MGRNAN eisseria gonorrhoeae, Miscellaneous Sites, by Nucleic Acid Amplification MCRNAC hlamydia trachomatis, Miscellaneous Sites, by Nucleic Acid Amplification MCTGCM iscellaneous Chlamydia trachomatis and Neisseria gonorrhoeae by Nucleic Acid Amplification, Varies TVRNAT richomonas vaginalis by Nucleic Acid Amplification, Varies MTRNAT richomonas vaginalis, Miscellaneous Sites, by Nucleic Acid AmplificationPARASITOLOGY CRYPSC ryptosporidium Antigen, Feces CYCLC yclospora Stain , Feces LEUF ecal Leukocytes, Feces FILF ilaria, Blood GIARG iardia Antigen, Feces LMALPM alaria PCR with Parasitemia Reflex, Varies MTBSM icrosporidia Stain, Varies OAPOva and Parasite, Concentrate and Permanent Smear, Microscopy, Feces PINWP inworm Exam, Perianal MALR apid Malaria/Babesia Smear, VariesINFECTIOUS DISEASE SEROLOGY ANAPA naplasma phagocytophilum (Human Granulocytic Ehrlichiosis) Antibody, Serum ARBOPA rbovirus Antibody Panel, IgG and IgM, Serum ABOPCA rbovirus Antibody Panel, IgG and IgM, Spinal Fluid ASPBAA spergillus Antigen, Bronchoalveolar Lavage ASPAGA spergillus (Galactomannan) Antigen, Serum BABGB abesia microti IgG Antibodies, Serum BARTB artonella Antibody Panel, IgG and IgM, Serum BLASTB lastomyces Antibody, Enzyme Immunoassay, Serum SBLB lastomyces Antibody by Immunodiffusion, Serum CBLB lastomyces Antibody by Immunodiffusion, Spinal Fluid BORDGB ordetella pertussis Antibody, IgG, Serum BRUGMB rucella Antibody Screen, IgG and IgM, Serum BRUTAB rucella Total Antibody Confirmation, Agglutination, Serum CAVPCC alifornia Virus (La Crosse) Encephalitis Antibody Panel, IgG and IgM, Spinal Fluid CAVPC alifornia Virus (La Crosse) IgG and IgM, Serum CHIKVC hikungunya IgM and IgG, Antibody, Serum SCLAMC hlamydia Serology, SerumPage 4 of 4T244 MC0767rev0220 Patient Information (required)Patient ID (Medical Record No.)

9 Client Account No. Patient Name (Last, First, Middle)Client Order Date (Month DD, YYYY) SCOCC occidioides Antibody, Serum CCOCC occidioides Antibody, Spinal Fluid COXISC occidioides Antibody with Reflex, Serum PLFAC ryptococcus Antigen Screen, Lateral Flow Assay, Pleural Fluid PLFATC ryptococcus Antigen Titer, Lateral Flow Assay, Pleural Fluid SLFATC ryptococcus Antigen Titer, LFA, Serum CLFATC ryptococcus Antigen Titer, LFA, Spinal Fluid ULFAC ryptococcus Antigen Screen, Lateral Flow Assay, Urine SLFAC ryptococcus Antigen Screen with Titer, Serum CLFAC ryptococcus Antigen Screen with Titer, Spinal Fluid LFACXC ryptococcus Antigen with Reflex, Spinal Fluid CMVGC ytomegalovirus (CMV) Antibodies, IgG, Serum CMVPC ytomegalovirus (CMV) Antibodies, IgM and IgG, Serum CMVMC ytomegalovirus (CMV) Antibodies, IgM, Serum DENVPD engue Virus Antibody/Antigen Panel, Serum DENGMD engue Virus Antibody, IgG and IgM, Serum DNSAGD engue Virus NS1 Antigen, Serum DTABSD iphtheria/Tetanus Antibody Panel, Serum DIPGSD iphtheria Toxoid IgG Antibody, Serum EEEPE astern Equine Encephalitis Antibody, IgG and IgM, Serum EEPCE astern Equine Encephalitis Antibody Panel, IgG and IgM, Spinal Fluid ECHNOE chinococcus Antibody, IgG, Serum EHRCPE hrlichia Antibody Panel, Serum EHRCE hrlichia chaffeensis (HME) Antibody, IgG, Serum SAME ntamoeba histolytica Antibody, Serum SEBVE pstein-Barr Virus (EBV) Antibody Profile, Serum EBVEE pstein-Barr Virus (EBV), IgG Antibody to Early Antigen, Serum HIBSH aemophilus influenzae Type B Antibody, IgG, Serum HSVGH erpes Simplex Virus (HSV)

10 Type 1- and Type 2-Specific Antibodies, IgG, Serum HICBLH istoplasma/Blastomyces Panel, Spinal Fluid SHSTOH istoplasma Antibody, Serum CHISTH istoplasma Antibody, Spinal Fluid UHISTH istoplasma Antigen, Urine MONOSI nfectious Mononucleosis, Rapid Test, Serum SFLAI nfluenza Virus A Antibodies, IgG and IgM (Separate Determinations), Serum SFLBI nfluenza Virus B Antibodies, IgG and IgM (Separate Determinations), Serum LAGUL egionella Antigen, Urine SLEGL egionella pneumophila (Legionnaires Disease), Antibody, Serum LEISL eishmaniasis (Visceral) Antibody, Serum LEPDTL eptospira, IgM, Serum LNBABLyme Central Nervous System Infection IgG with Antibody Index Reflex, Serum and Spinal Fluid LY WBLyme Disease Antibody, Immunoblot, Serum ELYMELyme Disease European Antibody Screen, Serum ELYMILyme Disease European Immunoblot, Serum LYMELyme Disease Serol