Diagnostic Lab Request Form - Stanford Medicine · LAB USE ONLY C NC Samples Received: Contact Us...

Preview:

Citation preview

LAB USE ONLY

C NC Samples Received:

Contact Us by-- PHONE: (650) 723-3878 FAX: (650) 725-0928 EMAIL: diagnosticlab@stanford.edu Drop Off: 300 Pasteur Drive, Edwards Bldg. R320, Stanford, California 94305

Diagnostic Lab Request Form Stanford University, Department of Comparative Medicine

Red outlined items must be provided.

Medical Emergency STAT (Clinical Staff Only)

End of day ASAP (Additional charges may apply)

List Chemistry Analyte Priorities:

Investigator (PI): Responsible Person:

Phone/contact: ACCOUNT NUMBER/PTA #:

Animal ID(S):

Animal Name:

SPECIES: Breed/Strain: Age: Sex: Bldg: Room: Cage/Barcode:

Medical Record #: Protocol #: Date Submitted: Collection Date/Time: Requested By: Need Results? Provide your email:

OK to dilute short samples? Y ☐ N ☐

Diagnostic Combo Profile Hematology Microbiology/Body Fluids Rodent/Hamster Panels CBC/Chem/Lytes 901-3 Source: CBC/Liver 970-2

CBC/Metabolic 964-6

CBC/Lipid 967-9

1018

1016

Chemistry 1006

2020 1028 Infectious Disease

Albumin ALTAlk. PhosASTBilirubinBUNCalciumChloride

Chemistry w/ lytes 2000, 2, 4

CO2 CreatinineGGTGlobulinGlucose Phosph.PotassiumSodium

Cholesterol T. Protein

1200 Serology PCR

Endocrinology (Pre 2300, Post 2302)Idx

2318Corn

2215 CSU

2322Anily

2310Corn

2307Corn

Mouse Parvovirus (MPV/MVM)

2295MSU MHV

2110 Urine MNV

Collection Method: LCMV

2005, 6, 9 (Cholesterol, Triglyceride, HDL, LDL)

EDIM

4000 Parasitology PVM

2013-15 5014 Rat Parvovirus (RPV,RMV, KRV, H-1)

RCV/SDA Virus

2010-12 (Na, K, Cl, CO2, BUN, Creat, Glu)

2138,39 5000, 10 Sendai Virus

2148 SV-5

922 2143 TMEV (GD-7)

910 2136 5028 Other:

2140 Additional Tests Biomarker Immunoassay 2241

2131 2165 Aub 2204

2074, 5, 7 Water Quality 2313 Aub

2050/2, 2113/7, 2115/9 2363

Temp Monochloramine

2164 Aub

2162 2210 MSU Additionally Available 2007 2194 Corn i-Stat Handheld Rental2175 2190 Corn Biological Material Pathogen Test

2084, 101, 85 Blood Gas Analyzer Use 2199 Custom Panels for your study

2048, 51, 49 … or Hundreds of Other Tests! Please contact us to serve you better 2082, 100, 83

Clinical Summary: Hx, clinical signs, Tx, experimental procedures and suspected diagnosis:

Mouse Phenotyping Profiling 947, 8Pre-Clinical Toxicity Profile 949

Chemistry No Lytes

Lipid Panel

Liver Panel(ALT, AST, ALKP, Bili, GGT)

Electrolyte Panel (Na, K, Cl, CO2, Na/K Ratio, AnGap)

Metabolic Panel

Avian Comprehensive ProfileReptile Profile

Amylase/Lipase 2086/8, 2102/3, 2087/9

Cardiac Biomarker Panel 2019

BNP cCRP Troponin ICK TotalHDL/LDLHemoglobin A1CTotal IronLactic AcidMagnesiumTIBCTriglycerideUric Acid

CBC (incl. diff, plt & retic) 1000-1004

Differential Only (Manual) 1050

Extra slide: Stained Y / N 1208 Type of stain:

HematocritHemoglobinHemogram onlyPlatelet CountReticulocyte Count

CortisolEstradiolFructosamineInsulinProgesteroneTestosteroneNonK9Thyroid (TT3, TT4, FT4) 2280MSU

TSH Stimulation

UrinalysisUrine Culture ID SensitivityUrine CreatinineUrine GlucoseUrine MagnesiumUrine ProteinUC, UP, RatioU. Electrolytes (Na, Cl, K) 2133UNa, UK, Ratio

Basic Panel (RO) pH Conductivity

Comprehensive (incl. Basic) 2360

Ammonia Copper ULR Cl.

Dissolved O2 Nitrate Nitrite

Total Cl. Alkalinity Hardness

Aerobic Culture ID SensitivityAnaerobic Culture IDBlood CultureCampylobacter Only CultureColony CountClostridium difficileCytologyCytospin OnlyEnteric CultureCampy/Salmonella/Shigella/Yersinia

Environmental Culture Fluid Analysis Cell CountFluid Analysis CytologyFungal CultureGram StainAcid-fast StainAcid-fast CultureOccult BloodRodac Plate

Mini Serology PanelMini Health Panel (no micro)Mini Health Panel (w/micro)Comp. Serology PanelComp. Health Panel (no micro)Comp. Health Panel (w/micro)Rederivation Profile (no micro)

Corneybacterium bovisHelicobacter spp.Mycoplasma polmonisPasteurella pneumotropicaPseudomas aeruginosaStaphylococcus aureusStaphyloccucus xylosus

Cecal ExamEctoparasite (skin scrape) 5046

Ova & Parasite Fecal Float OR SedimentParasitology Panel (NHP/Pig)Protozoal Stain

Blood Storage/SpinCyclosporineDigoxinPhenobarbitalSeleniumVitamin B12Vitamin 12Other

Mouse ProgesteroneMouse FerritinOther

Recommended