Heavy Metal Patient Demographic Form

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110 W. Cliff Ave., Spokane WA 99204 • Toll Free: 800.349.8586 • Fax: 509.924.5127 •
Account Number:
Your state law now requires testing laboratories to report
the following demographic information whether the order is
Account Name:
placed manually OR electronically. Failure to complete the
Address:
information in the area below may result in a follow-up call
from your state or local health department.
City:
State:
Zip:
PATIENT INFORMATION
TEST ORDER INFORMATION
Check one of the following:
Name: Last
First
MI
DEMARS
Arsenic, Blood
DEMASU
Arsenic, Urine Random
Sex:
Date of Birth:
DEMCDB
Cadmium, Blood
Patient ID #:
DEMCDO
Cadmium Exposure Panel - OSHA
DEMCDU
Cadmium, Urine Random
Address:
DEMOSH
Lead and ZPP OSHA Prof
City:
State:
Zip:
DEMOPB
Lead, Blood
DEMOHG
Mercury, Blood
County:
Phone: (
)
-
DEMHGU
Mercury, Urine Random
Patient demographics only, order already placed
Race:
Ethnicity:
electronically.
Medicaid #:
SAMPLE AND TEST INFORMATION
The following information MUST be provided:
Patient SSN:
-
-
Sample Collection Date:
Sample Type (check one):
Venous
If the patient is a CHILD under 16 years of age, complete
Urine
the following:
Purpose (check one):
Parent or
Guardian
Child Screen
Follow-up Test
Name: Last
First
Clinical Suspicion
Repeat Test
Employee Screen
Other
If the patient is an ADULT, complete the following:
ORDERING PHYSICIAN INFORMATION
Patient Occupation:
The physician’s name MUST be provided:
Employer Name:
Physician’s Name: Last
First
Address:
Employer Address:
Phone #: (
)
-
Employer Phone #: (
)
-
NPI #:
Heavy Metal Patient Demographic Form - REV100815

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