Clinical Laboratory Test Requisition Form
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1NH PUBLIC HEALTH LABORATORIES
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PHL Barcode Only
29 Hazen Drive, Concord, NH 03301
Telephone: 603-271-4661, Fax: 603-271-2138
CLINICAL LABORATORY TEST REQUISITION
TEST LIST
NOTE:
Ab = Antibody
Ag = Antigen
OUTBREAK INFO: _______ Please check if specimen is part of an outbreak
MYCOBACTERIA (AFB) (TB)
Outbreak Comments: _____________________________________________________
EPIDEMIOLOGY STUDY
_
NAA Direct Test
(Isolate or specimen)
(Respiratory specs only)
SUBMITTER INFORMATION -
Bacillus anthracis
_ R/O
Please Print Legibly
_
Culture & Smear
_ R/O Brucella spp
_
Mycobacteria ID
Submitter Facility Name: ___________________________________
_ R/O Burkholderia spp
LEGIONELLA
_ R/O
Francisella tularensis
Address: _______________________________________________
_
Culture
Yersinia pestis
_ R/O
_
DFA
City: _____________________ State: ______
Zip: ___________
Bacillus cereus
_
MYCOLOGY
_
B. pertussis
Telephone No.: ___________________ Fax No.: _______________
_
Cryptococcal Ag
_ Campylobacter spp
_
C. botulinum/tetani
Fungal Culture
_
Physician
: ______________________________________
(Full Name)
_
C. diphtheriae
_
Mold ID
OTHER Report to: _______________________________________
_
_ Cryptosporidium
Yeast ID
PARASITOLOGY*
_ EHEC/Shiga-like toxin
National Provider Identifier #: _______________________________
H. influenzae
_
_
*Blood Parasite
PERTUSSIS
_ Legionella spp
PATIENT INFORMATION -
Please Print Legibly
_ Listeria spp
_
Culture
NOTE: All specimens MUST have Date of Birth and Date of Collection;
M. tuberculosis
_
_
_
PCR
Medicaid patients need Medicaid # and ICD (Diagnosis) Code for billing purposes
_
N. gonorrhoeae
SYPHILIS
N. meningitidis
_
_
RPR – Qual - Screen
_ Plasmodium/Babesia
_
RPR – Quant - Titer
Last Name: ________________________________________________
_ Salmonella spp
_
TP-PA
_ Shigella spp
_
VDRL (CSF only)
_
Strep. pneumoniae
First Name: ________________________________________________
VIRUS CULTURE (ONLY)
_ Vibrio spp
_
Enterovirus
_ Yersinia spp
D.O.B:
Age: ________
Sex:
M
F
_
Herpes
_
M M / D D / Y Y
Mumps
BACTERIAL CULTURE/ISOLATE ID
_
_
Respiratory
Address: __________________________________________________
Aerobic
_
Varicella-Zoster
_
Anaerobic
_
Other________________
_
Antimicrobial Susceptibility
City: ____________________ State: _________ Zip: _____________
VIRUS TESTING
_
Enteric Culture
_
Arbovirus IgM
o Screen (Salm, Shig only)
Patient Tel #: _______________________________________________
_
Chikungunya RT-PCR
o Full (Salm, Shig, Campy, Aero,
_
Herpes 1&2 IgG Ab
Plesio, EHEC, Yersinia)
Patient Medicaid #: __ __ __ __ __ __ __ __ __ __ __ State: ___NH ___VT
_
Measles (Rubeola) IgG
_
Isolate ID: _____________
_
Measles (Rubeola) IgM
_
Other: ________________
ICD – 10 Diagnosis (
) Code: __ __ __ __ __
_
DX
Measles RT-PCR
CHEMISTRY
_
_
Mumps IgG
Arsenic, Urine
Race (Circle One):
WHITE
BLACK
ASIAN
NATIVE–American/Alaskan
_
_
Mumps IgM
Mercury, Blood
_
MULTIRACIAL
HAWAIIAN/PACIFIC ISLANDER
UNKNOWN
OTHER ___________
CHLAMYDIA
Mumps RT-PCR
_
_
Norovirus RT-PCR
Amplified
Ethnicity (Circle One):
NON-HISPANIC HISPANIC UNKNOWN
_
_
Respiratory Panel
Culture
_
GONORRHEA
Patient ID #: ______________________________________________
Rubella IgG
_
_
Rubella IgM
Amplified
DATE of collection: ________________
SPECIMEN INFORMATION:
_
_
Varicella-Zoster DFA
Culture
_
HEPATITIS
Varicella-Zoster IgG
TIME of collection: ________________
_
_
A IgM Ab
Zika*
_
Pregnancy Status: Y N
SITE/SOURCE of Specimen (please check):
A Total Ab
_
_
Other: _______________
B Core IgM Ab
___ Serum
___ Rectal
_
B Core Total Ab
___ Whole Blood
___ Stool
_
B Surface Ab
___ Sputum
___ Throat
_
B Surface Ag
___ Induced Sputum
___ Urethra
_
C Ab – Screen
___ Bronchial Washing
___ Urine
_
C Genotyping
___ CSF
___ Other (Specify) ______________
_
C RNA Quantitative
HIV
PHL LAB USE ONLY
___ Cervix
___ Tissue (Specify) ______________
_
___ Nasopharyngeal
___ Fluid (Specify) _______________
HIV Ag/Ab Combo
_
HIV-1/2/Group O – Screen
Date of Onset of Symptoms:
(
)
Decedent only
PATIENT TRAVEL HISTORY: (Please supply date(s) and location)
*
Other Test Requested or Additional Comments and Remarks: ____________________________________________________________________________________2/12/16
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