Patient Information Form
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1Public Health Laboratory
County of Santa Clara
LABORATORY USE ONLY
2220 Moorpark Ave.,2nd Fl., San Jose, CA 95128
(408) 885-4272 FAX (408) 885-4275
Patricia A. Dadone, Laboratory Director
LAB NUMBER
DATE/TIME
CLIA NO.: 05D0643967 / NPI NO: 1528165883
INFORMATION BELOW MUST BE PROVIDED BEFORE REQUISITION WILL BE PROCESSED
Patient Name (Last)
(First)
(M)
Sex
Date of Birth (DOB)
Social Security No. (SSN)
-
-
M
F
Address
Street
City
State
Zip
Patient Telephone Number
Patient ID Number
Medical Record Number
Submitting Laboratory's Specimen ID Number
Date Specimen Taken
Date of Onset
Next CHDP Visit
Patient History/Travel History
Reason For Testing
[ ] Contact
[ ] Clearance
[ ] Screen
[ ] Immunity Status
[ ] Other
Type of Specimen
[ ] Blood
[ ] CSF
[ ] Urine
[ ] Cervix
[ ] Rectal
[ ] Urethral
[ ] Throat
[ ] Naso-Pharyngeal
[ ] Feces
[ ] Serum
[ ] Wound
[ ] Sputum
[ ] Gastric
[ ] Skin
[ ] Plasma (Heparin)
[ ] Other
ORDERING PHYSICIAN INFORMATION
Name (physician's name)
UPIN #
ICD-9 code (diagnosis code required)
COMPLETE INFORMATION & A COPY OF INSURANCE CARD
SUBMITTER INFORMATION
MUST BE ATTACHED OR SUBMITTER WILL BE BILLED
IMPRINT PLATE OR HAND WRITTEN
Responsible Party
Relationship (circle one)
Self / Spouse / Child / Other
Name
Address
Street
City
Zip
Address
Responsible Person:
Telephone
Bill to / Insurance Number:
City
State
Zip
[ ] Submitter [ ] Medi-Cal [ ] Blue Cross - Medi-Cal
[ ] Medicare
Telephone
[ ] CHDP
[ ] VHP
[ ] Other
Contact _______________________
[ ] CCAH
FAX
Check Test Being Ordered and Source
BACTERIOLOGY:
VIROLOGY:
MOLECULAR TESTING:
[ ] G
[ ] Gonorrhea Smear
h
S
[ ] R
[ ] Respiratory Panel Culture
i t
P
l C lt
[ ] G
[ ] Gonorrhea - molecular method
h
l
l
th d
[ ] Cervix
[ ] Respiratory Panel - direct smear
[ ] Cervix
[ ] Pharyngeal
[ ] Chlamydia - direct smear
[ ] Urethra
[ ] Rectal
[ ] Cervix
[ ] Urine
[ ] Urethra
[ ] Eye
[ ] Pharyngeal
[ ] Rectal
[ ] Gonorrhea Culture
[ ] Rectal
[ ] Throat
[ ] Pharyngeal
[ ] Chlamydia - molecular method
[ ] Rectal
[ ] Urethra
[ ] Cervix
[ ] Herpes 1/2 DFA
[ ] Urine Culture
[ ] Urethra
[ ] B. pertussis DFA
[ ] Urine
[ ] B. pertussis culture
VIRAL SEROLOGY
[ ] Pharyngeal
(red or tiger top):
[ ] MRSA
[ ] HBsAg
[ ] Rectal
[ ] Streptococcus (Strep A)
[ ] HBcore Total
[ ] Bordetella pertussis
[ ] Enteric culture (primary stool)
[ ] HCV
[ ] Influenza (A/B)
Salmonella / Shigella / E. coli O157 (
)
[ ] HIV (serum)
[ ] Influenza subtyping
circle one
[ ] Shiga-Toxin Immunoassay
[ ] HIV (oral fluid )
[ ] Avian Influenza
[ ] Measles IgG
[ ] Norovirus
[ ] Measles IgM
SEROLOGY:
[ ] Measles
[ ] RPR
[ ] Herpes 1/2 IgG
[ ] Mumps
(red or tiger top)
[ ] previous positive
[ ] West Nile Virus
[ ] Dengue
[ ] TPPA
[ ] Darkfield microscopy
PARASITOLOGY:
MYCOLOGY
[ ] Ext. genitalia
[ ] Ova and Parasites
[ ] Fungal culture
[ ] Int. genitalia
[ ] Pinworm
[ ] Yeast culture
[ ] Oral
[ ] Cryptosporidia
[ ] Helminth identification
SPECIAL TEST REQUEST(S)
MYCOBACTERIOLOGY / TB:
[ ] Arthropod identification
[ ] Quantiferon-TB Gold In-Tube Assay
[ ] Blood film
[ ]
[ ] NAAT - GenXpert
[ ] Malaria speciation
[ ] Culture
[ ] B. burgdorferi (tick ID & test)
[ ]
[ ] Sensitivities (1st line drugs)
[ ] Molecular Beacon
CHEMISTRY/ TOXICOLOGY:
[ ] Pyrosequencing
[ ] Blood Lead - capillary screen
[ ] Blood Lead - venous confirmation
revised 10/31/13
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