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Home My WebLink Aboutncov-batch-submittal-form Alameda County Public Health Laboratory BATCH Specimen Submittal Form Division of Communicable Disease Control and Prevention Please call the AC PHL at (510) 382-4300 if you have any questions regarding specmen submission. Complete this form electronically and submit to acphl@acgov.org ATTN: PHL 2901 Peralta Oaks Court, Oakland, CA 94605 Phone (510) 382-4300 Fax (510) 382-4333 Submitter (ACPHL Account name): Site / Facility Submitter Email Address: Ordering Clinician Last Name:Clinician First Name: Facility Mailing Address: Facility Phone Number: Test(s) Requested:SARS-CoV-2 PCR Patient Patient Date of Specimen source Specimen Specimen Submitter Specimen Patient Address Patient Address patient Patient PatientPMedical EthniPregnancy Symptomatic/ Comments Patient Last NamePatient First NameBirth Sexpatient cityRace(OTHER? Please Collection DateCollection Time ID12stateZip Codehone #Record cityStatusAsymptomatic (MM/DD/YYYY)provide comment)(MM/DD/YYYY)(24HHMM) Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Page 1 of 6 Alameda County Public Health Laboratory BATCH Specimen Submittal Form Division of Communicable Disease Control and Prevention Please call the AC PHL at (510) 382-4300 if you have any questions regarding specmen submission. Complete this form electronically and submit to acphl@acgov.org ATTN: PHL 2901 Peralta Oaks Court, Oakland, CA 94605 Phone (510) 382-4300 Fax (510) 382-4333 Submitter (ACPHL Account name): Site / Facility Submitter Email Address: Ordering Clinician Last Name:Clinician First Name: Facility Mailing Address: Facility Phone Number: Test(s) Requested:SARS-CoV-2 PCR Patient Patient Date of Specimen source Specimen Specimen Submitter Specimen Patient Address Patient Address patient Patient PatientPMedical EthniPregnancy Symptomatic/ Comments Patient Last NamePatient First NameBirth Sexpatient cityRace(OTHER? Please Collection DateCollection Time ID12stateZip Codehone #Record cityStatusAsymptomatic (MM/DD/YYYY)provide comment)(MM/DD/YYYY)(24HHMM) Number 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 Page 2 of 6 Alameda County Public Health Laboratory BATCH Specimen Submittal Form Division of Communicable Disease Control and Prevention Please call the AC PHL at (510) 382-4300 if you have any questions regarding specmen submission. Complete this form electronically and submit to acphl@acgov.org ATTN: PHL 2901 Peralta Oaks Court, Oakland, CA 94605 Phone (510) 382-4300 Fax (510) 382-4333 Submitter (ACPHL Account name): Site / Facility Submitter Email Address: Ordering Clinician Last Name:Clinician First Name: Facility Mailing Address: Facility Phone Number: Test(s) Requested:SARS-CoV-2 PCR Patient Patient Date of Specimen source Specimen Specimen Submitter Specimen Patient Address Patient Address patient Patient PatientPMedical EthniPregnancy Symptomatic/ Comments Patient Last NamePatient First NameBirth Sexpatient cityRace(OTHER? Please Collection DateCollection Time ID12stateZip Codehone #Record cityStatusAsymptomatic (MM/DD/YYYY)provide comment)(MM/DD/YYYY)(24HHMM) Number 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 Page 3 of 6 Alameda County Public Health Laboratory BATCH Specimen Submittal Form Division of Communicable Disease Control and Prevention Please call the AC PHL at (510) 382-4300 if you have any questions regarding specmen submission. Complete this form electronically and submit to acphl@acgov.org ATTN: PHL 2901 Peralta Oaks Court, Oakland, CA 94605 Phone (510) 382-4300 Fax (510) 382-4333 Submitter (ACPHL Account name): Site / Facility Submitter Email Address: Ordering Clinician Last Name:Clinician First Name: Facility Mailing Address: Facility Phone Number: Test(s) Requested:SARS-CoV-2 PCR Patient Patient Date of Specimen source Specimen Specimen Submitter Specimen Patient Address Patient Address patient Patient PatientPMedical EthniPregnancy Symptomatic/ Comments Patient Last NamePatient First NameBirth Sexpatient cityRace(OTHER? Please Collection DateCollection Time ID12stateZip Codehone #Record cityStatusAsymptomatic (MM/DD/YYYY)provide comment)(MM/DD/YYYY)(24HHMM) Number 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 Page 4 of 6 Alameda County Public Health Laboratory BATCH Specimen Submittal Form Division of Communicable Disease Control and Prevention Please call the AC PHL at (510) 382-4300 if you have any questions regarding specmen submission. Complete this form electronically and submit to acphl@acgov.org ATTN: PHL 2901 Peralta Oaks Court, Oakland, CA 94605 Phone (510) 382-4300 Fax (510) 382-4333 Submitter (ACPHL Account name): Site / Facility Submitter Email Address: Ordering Clinician Last Name:Clinician First Name: Facility Mailing Address: Facility Phone Number: Test(s) Requested:SARS-CoV-2 PCR Patient Patient Date of Specimen source Specimen Specimen Submitter Specimen Patient Address Patient Address patient Patient PatientPMedical EthniPregnancy Symptomatic/ Comments Patient Last NamePatient First NameBirth Sexpatient cityRace(OTHER? Please Collection DateCollection Time ID12stateZip Codehone #Record cityStatusAsymptomatic (MM/DD/YYYY)provide comment)(MM/DD/YYYY)(24HHMM) Number 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 Page 5 of 6 Alameda County Public Health Laboratory BATCH Specimen Submittal Form Division of Communicable Disease Control and Prevention Please call the AC PHL at (510) 382-4300 if you have any questions regarding specmen submission. Complete this form electronically and submit to acphl@acgov.org ATTN: PHL 2901 Peralta Oaks Court, Oakland, CA 94605 Phone (510) 382-4300 Fax (510) 382-4333 Submitter (ACPHL Account name): Site / Facility Submitter Email Address: Ordering Clinician Last Name:Clinician First Name: Facility Mailing Address: Facility Phone Number: Test(s) Requested:SARS-CoV-2 PCR Patient Patient Date of Specimen source Specimen Specimen Submitter Specimen Patient Address Patient Address patient Patient PatientPMedical EthniPregnancy Symptomatic/ Comments Patient Last NamePatient First NameBirth Sexpatient cityRace(OTHER? Please Collection DateCollection Time ID12stateZip Codehone #Record cityStatusAsymptomatic (MM/DD/YYYY)provide comment)(MM/DD/YYYY)(24HHMM) Number 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 Page 6 of 6