Limited Testing Registration Page 7

ADVERTISEMENT

8. TESTING CATEGORIES REQUESTED: Please check off the testing category you are requesting and indicate the tests you are
performing, or intend to perform.
MICROBIOLOGY: BACTERIOLOGY AND VIROLOGY
Annual Test Volume: _______________
[ ] Rapid strep antigen
Name of kit: ___________________
Name of manufacturer: _________________
[ ] Influenza A
Name of kit: ___________________
Name of manufacturer: _________________
[ ] H. pylori (presumptive identification)
Name of kit: ___________________
Name of manufacturer: _________________
CHEMISTRY
Annual Test Volume: _______________
[ ] Blood glucose, by glucose monitoring devices approved by the FDA for home use
Name of instrument: ___________________________ Name of manufacturer: _________________________________
[ ] Blood cholesterol, by cholesterol monitoring device approved by the FDA for home use
Name of instrument: ___________________________ Name of manufacturer: _________________________________
[ ] Cholestech LDX system for total cholesterol, HDL cholesterol, triglycerides, glucose
[ ] Glycosylated Hemoglobin (HgbA1C)
Name of instrument: ___________________________ Name of manufacturer: _________________________________
[ ] LXN Fructosamine Test System
DIAGNOSTIC IMMUNOLOGY
Annual Test Volume: _______________
[ ] Rapid Mono (whole blood)
Name of kit: ___________________
Name of manufacturer: _________________
[ ] Bladder tumor antigen
Name of kit: ___________________
Name of manufacturer: _________________
[ ] H. pylori (whole blood antigen
detection)
Name of kit: ___________________
Name of manufacturer: _________________
ENDOCRINOLOGY
Annual Test Volume: _______________
[ ] Ovulation tests-visual color for
Name of kit: ___________________
Name of manufacturer: _________________
human luteinizing hormone
[ ] Urine pregnancy test-visual color
Name of kit: ___________________
Name of manufacturer: _________________
comparison
HEMATOLOGY AND MISCELLANEOUS TESTS
Annual Test Volume: _______________
[ ] Hemoglobin-copper sulfate method or other non-automated method
[
] Spun microhematocrit
(indicate method) : _____________________________
[
] Wampole STAT-CRIT
[ ] Hemoglobin by copper sulfate or by single analyte instruments
Name of instrument: ___________________________ Name of manufacturer: ____________________________
[ ] Erythrocyte sedimentation rate (non-automated)
[ ] Prothrombin time
Name of instrument: ____________________
Name of manufacturer: _______________________
TOXICOLOGY
Annual Test Volume: _______________
Name of kit: ___________________
Name of manufacturer: _________________
[ ] Saliva Alcohol Test
Name of kit: ___________________
Name of manufacturer: _________________
[ ] Urine Drug Test
URINALYSIS AND MISCELLANEOUS TESTS
Annual Test Volume: _______________
[ ] Dipstick or tablet reagent urinalysis (non-automated)
[ ] Bayer Clinitek 50 Analyzer
[ ] SmithKline Gastroccult-gastric occult blood
[ ] Fecal occult blood
[ ] Body fluid pH (other than blood)-all qualitative color comparison pH testing
PROVIDER PERFORMED MICROSCOPIC PROCEDURES
Annual Test Volume: _______________
[ ] Potassium hydroxide (KOH) preparations
[ ] Pinworm examinations
[ ] Wet Mounts
[ ] Fern tests
[ ] Nasal smears for eosinophils
[ ] Fecal leukocyte examinations
[ ] Urinalysis, microscopic only
[ ] Qualitative semen analysis (limited to the presence or absence of sperm and/or detection of motility)
[ ] Post-coital direct, qualitative examination of vaginal or cerival mucus
OTHER TESTS
Annual Test Volume: _______________
List Test, Method or Instrument Used. If needed, use a separate sheet of paper.
DOH-4081
(04/03)
4

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Limited Partnership Registration Information Change Form - Utah Department Of Commerce Limited Partnership Registration Information Change Form - Utah Department Of Commerce Legal
Limited Partnership Registration Information Change Form Addendum - Department Of Commerce Limited Partnership Registration Information Change Form Addendum - Department Of Commerce Legal
Limited Partnership Registration Information Change Form - Utah Department Of Commerce Limited Partnership Registration Information Change Form - Utah Department Of Commerce Legal
Amendment To Certificate Of Limited Partnership Or Foreign Limited Partnership Registration 2005 Amendment To Certificate Of Limited Partnership Or Foreign Limited Partnership Registration 2005 Legal
Form Bus56 - Amendment To Certificate Of Limited Partnership Or Foreign Limited Partnership Registration - 2004 Form Bus56 - Amendment To Certificate Of Limited Partnership Or Foreign Limited Partnership Registration - 2004 Legal
Akc Canine Good Citizen Test Registration Form Akc Canine Good Citizen Test Registration Form Business
Auditor's Limited Participant Registration Form And User Agreement Auditor's Limited Participant Registration Form And User Agreement Life
Form Sosbs Ars29349 - Foreign Limited Partnership Registration - 2015 Form Sosbs Ars29349 - Foreign Limited Partnership Registration - 2015 Legal
Form Flp-2 - Certificate Of Change Of Foreign Limited Partnership Registration Form Flp-2 - Certificate Of Change Of Foreign Limited Partnership Registration Legal
Foreign Limited Partnership Registration Form Foreign Limited Partnership Registration Form Legal

Related Categories

Parent category: Life
Download
Go
Page of 8