HomeMy WebLinkAboutacphd-requisition-form-for-bacterial-isolates-2-S:\PHLabs\PHL OFFICE\Forms - Submittal\General Requisition Form\Updated Test Req Form\ACPHL_PO_Test Req FormRev072523.xlsx
SPECIMEN INFORMATION
BILL TO: Patient SSN:
□ MediCal
□ Alliance ALLIANCE Referring Physician:
□ CMSP Physician License #
□ Other: Provide copy of Card (front and back) National Provider ID # DATE OF SERVICE: ICD-10 CODE(S) / DIAGNOSIS:
DATE SPECIMEN TAKEN: PREGNANCY STATUS:
TIME TAKEN: DISEASE SUSPECTED: PATIENT HISTORY: REASON FOR TESTING: □ Clearance DATE OF ONSET:
□ Serum □ Stool □ Sputum □ Tissue
□ Plasma □ Urine □ Induced Sputum □ Swab
□ Blood □ CSF □ Aspirate □ Wound □ Other
TESTING ORDERED
ENTERIC BACTERIOLOGY □ Salmonella □ Shigella □ Salmonella typhi □ Stool Culture □ E. coli O157 □ STEC □ Shiga Toxin Gene 1/2 Detection (PCR) □ Other
BACTERIOLOGY
(Analysis by whole genome sequencing) □ Aerobic Culture and Definitive ID
□ Anaerobic Culture and Def. ID □ Bacterial Isolate Definitive ID
□ Neisseria sp. Definitive ID □ Bordetella pertussis, Definitive ID □ CRE (carbapenem resistant enterobacteriaciae) □ Oth
□ er
MYCOBACTERIOLOGY / AFB □ AFB Smear / Culture / ID □ AFB isolate Definitive ID □ TB Drug Susceptibility □ M. tuberculosis complex PCR □ Other
MYCOLOGY/ FUNGAL □ Fungal Culture and ID □ Fungal isolate Definitive ID □ Other
PARASITOLOGY □ Malaria □ Other
OTHER TESTS / REQUESTS:
HIV □ HIV EIA (Oral Fluid) (with reflex confirmation)
□ HIV Screen (serum/plasma) (with reflex confirmation) □ Confirmatory HIV antibody (Bio-Rad Geenius*)
*will include screening test SYPHILIS SEROLOGY
□ RPR (with TPPA as reflex confirmation) □ TPPA Only □ Other
OTHER IMMUNOLOGY □ Quantiferon-TB Gold
NAAT (nucleic acid amplification) □ SARS-CoV-2 (COVID-19) □ Respiratory
□ Influenza A/B Virus Panel □ Respiratory Syncytial Virus (RSV) (each test to the left) □ Measles □ Mumps □ Bordetella pertussis □ Norovirus
First Name:
Submitters identification of Organism:
Important: Enter your laboratory findings on reverse.
M.I.:
ALAMEDA COUNTY PUBLIC HEALTH LABORATORY
2901 Peralta Oaks Ct, 2nd Floor
NO.: 05D2090025
Varghese, Ph.D. HCLD(ABB), Laboratory Director
Med.Rec.No.: Acct:
Address: City: State: ZIP: Phone No: QIC:
SUBMITTER INFORMATION PATIENT INFORMATION
BOLD FIELDS ARE MANDATORY FOR SPECIMEN TESTING
COMPLETE BILLING INFORMATION MUST BE PROVIDED (no billing for mandated services)
□ Case
□ Confirmation □ Contact
□ Carrier □ Other Treated: □ No □ Yes
SPECIMEN SOURCE:
S:\PHLabs\PHL OFFICE\Forms - Submittal\General Requisition Form\Updated Test Req Form\ACPHL_PO_Test Req FormRev072523.xlsx
Submitter's Laboratory Findings
Cultures made from original clinical sample were: □ Pure □ Mixed
If mixed, list other organisms present:
Indicate colony count where applicable (e.g., urine):
Number of times organism: (a) isolated from patient:
(b) transferred in the laboratory:
Medium(s) on which primary growth was obtained:
Were stained smears or other preparations made directly from clinical material? □Yes □No
If yes, was this organism seen? □Yes □No
Medium on which organism is being submitted:
Date inoculated: _
Conditions of incubation prior to mailing: Temperature: Atmosphere: Length:
Indicate in chart below the results of your laboratory examinations of the pure cultures being submitted using symbols given in the key:
Morphology Hemolysis Base Used
TSI: Growth:
Loeffler's Pigmentation Falkow Lysine 2s0c Maltose
Proteolysis Malonate ss0c Sucrose
Pseudomonas
p
CO2
OF Medium
Agglutination reactions Other tests or comments
ATTACH any Automated (e.g., Vitek) results
A = acid + = positive negative ( ) = number of days