Lab Services IMPORTANT Patient instructions and map on back

LAB

PHYSICIAN ORDERS M Patient Patient __________________________________ ______________________ _______ D.O.B. _________ F SS# ____-___-______ Last Name First M.I.

Address ______________________________________ City ___________________________ Zip __________ Phone # _____________

Physician _____________________________________________________ ATTACH COPY OF PHSICIAN CARD

Diagnosis/ICD-9 Code ________________________________________ (Additional codes on reverse)

ROUTINE ASAP STAT

PHONE RESULTS TO:# _______________ FAX RESULTS TO: # ______________ COPY TO: _________________________

789.00 Abdominal Pain 285.9 Anemia (NOS)

414.9 Coronary Artery Disease (CAD) 250.0 DM (diabetes mellitus) 780.7 Fatigue/Malaise 272.0 Hypercholesterolemia

244.9 Hypothyroidism 272.4 Hyperlipidemia 401.9 Hypertension 485.9 URI (upper respiratory infection)

HEMATOLOGY CHEMESTRY CHEMESTRY MICROBIOLOGY

1021 CBC, Automated Diff (incl. Platelet Ct.) 1023 Hemoglobin/Hematocrit 1020 Hemogram 1025 Platelet Count 1150 Pro Time Diagnostic 1151 Pro Time Therapeutic 1155 PPT 1315 Reticulocyte Count 1310 Sed Rate/Westergren

5550 Alpha Fetoprotein, Prenatal 3000 Amylase 3153 B12/Folate 3156 Beta HCG, Quantitative 3321 Bilirubin, Total 3324 Bilirubin, Total/Direct 3009 BUN 3159 CEA 3348 Cholesterol 3030 Creatine, Serum 3509 Digoxin (recommended 12 hrs., after dose) 3515 Dilantin 3168 Ferritin 3193 FSH 3066 Glucose, Fasting 3061 Glucose, 1° Post 50 g Glucola 3075 Glucose, 2° Post Glucola 3060 Glucose, 2° Post Prandial (meal) 3049 Glucose Tolerance Oral GTT 3047 Glucose Tolerance Gestational GTT 3650 Hemoglobin, A1C

5232 HBsAg 3175 HIV (Consent required) 3581 Iron & Iron Binding Capacity 3195 LH 3590 Magnesium 3527 Phenobarbital 3095 Potassium 3689 Pregnancy Test, Serum (HGC, qual) 3653 Pregnancy Test, Urine 3197 Prolactin 3199 PSA 3339 SGOT/AST 3342 SGPT/ALT 3093 Sodium/Potassium, Serum 3510 Tegretol 3551 Theophylline 3333 Uric Acid

Source ___________________________________

7240 Culture, AFB 7200 Culture, Blood x _______________________ Draw Interval ______________________ 7280 Culture, Fungus Culture, Routine 7005 Culture, Stool 7010 Culture, Throat 7000 Culture, Urine 7300 Gram Stain 7355 Occult Blood x _________________________ 7365 Ova & Parasites x ______________________ 7400 Smear & Suspension

(includes Gram Stain/Wet Mount) 7060 Rapid Strep A Screen (Negs confir by cult) 7065 Rapid Strep A Screen only 7030 Beta Rapid Culture 5207 GC by DNA Probe 5130 Chlamydia by DNA Probe 5555 Chlamydia/GC by DNA Probe 7375 Wright Stain, Stool

URINE 1059 Urinalysis 1082 Urinalysis w/Culture if indicated Urine-24 Hr _______ Spot _______ Ht. _______Wt. ________ 3033 Creatine 3036 Creatine Clearance (also requires blood) 3398 Protein 3096 Sodium/Potassium Microalbumin 24 Hr ____ Spot ____

SEROLOGY 8020 ANA (Antinuclear Antibody) 8040 Mono Spot 3494 Rheumatoid Factor 8010 RPR 5365 Rubella

Additional Tests ___________________________________________________________________________________________________________________

PANELS & PROFILES

X 3309 CHEM 12 Albumin, Alkaline Phosphatase BUN, Calcium, Cholesterol, Glucose, LDH, Phosphorus, AST, Total Bilirubin, Total Protein, Uric acid

3315 CHEM 20 Chem 12, Electrolyte Panel, Creatine, Iron, Gamma GT, ALT, Triglycerides

3357 CARDIA RISK PANEL Cholesterol, HDL, LDL, Risk Factors, VLDL, Triglycerides

X 3042 CRITICAL CARE PANEL BUN, Chloride, CO2, Glucose, Potassium, Sodium

3046 ELECTROLYTE PANEL Chloride, CO2, Potassium, Sodium

3399 EXECUTIVE PANEL Chem 20, iron, Cardiac Risk Panel, CBC, RPR, Thyroid cascade

5242 HEPATITIS PANEL, ACUTE HAVIgMAb, HBsAg, HBsAb, HBcAb, HCVAb

3355 LIPID MONITORING PANEL Cholesterol, Triglycerides, HDL, LDL, VLDL, ALT, AST

3312 LIVER PANEL Alkaline Phosphatase, AST, Total Bilirubin, Gamma GT, Total Protein, Albumin, ALT

X 3083 METABOLIC STATUS PANEL BUN, Osmolality (calculated), Chloride, CO2 Creatine, Glucose, Potassium, Sodium, BUN/Creatine, Ratio, Anion Gap

X 3376 PANEL B Chem 12, CBC, Electrolyte Panel

3382 PANEL D Chem 20, CBC, Thyroid Cascade

X 3388 PANEL F Chem 12, CBC, Electrolyte Panel, Thyroid Cascade

3391 PANEL G Chem 20, Cardiac Risk Panel, CBC, Thyroid Cascade

3393 PANEL H Chem 20, CBC, Cardiac Risk Panel, Rheumatoid Factor, Thyroid Cascade

3397 PANEL J Chem 20, Cardiac Risk Panel

5351 PRENATAAL PANEL Antibody Screen, ABO/Rh, CBC Rubella, HBsAg, RPR 1059 with Urinalysis, Routine 1082 with Urinalysis, w/Culture if indicated

X 3102 RENAL PANEL Metabolic Status Panel, Calcium, Phosphorus

3188 Thyroid Cascade TSH, Reflex Testing

– patient required to fast for 12 -14 hours

X – patient recommended to fast for 12 -14 hours

LAB USE ONLY

SST PURPLE YELLOW BLUE GREEN GREY URINE BLACK OTHER: ________ REC’V. SPECIMEN: AMBIENT

INIT _________ PLASMA SERUM SWAB SLIDES DNA PROBE B. CULT BTLS

_____________________ FROZEN ON ICE

Special Instructions/Pertinent Clinical Information __________________________________________________________________________ Physician’s Signature _______________________________________________________________ Date __________________________ These orders may be FAXed to: 449-5288 7060-500 (7/96)