Laboratory Services Order Form - Clay County Hospital
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1911 Stacy Burk Dr. Flora, IL 62839
Phone: 618-662-1625
Fax: 618-662-4981
Laboratory Services Order Form
Facility Name:
Ordering Physician:
Patient Name:
DOB:
Social Security #:
Date & Time of Collection:
Please Choose One: FASTING Hours
DATE: TIME:
NON-FASTING
CHEMISTRY PANELS
DIAGNOSIS
MISC. TESTS
DIAGNOSIS
Electrolytes
DX:
Beta HCG Quant
DX:
Cholesterol
DX:
Bioavail. Testosterone
DX:
CMP
DX:
C- Reactive Protein
DX:
Ammonia
DX:
CBC
DX:
B12
DX:
ESR
DX:
DX:
Hgb/Hct
DX:
Amylase
CK
DX:
hsCRP-Cardiac
DX:
Chemistry
DX:
MONO
DX:
D-Dimer
DX:
Pregnancy Serum
DX:
Direct LDL
DX:
Pregnancy Urine
DX:
BNP
DX:
Protime
DX:
Folate
DX:
PTH
DX:
BMP
DX:
Retic Count
DX:
DX:
Strep Screen
DX:
CA 15-3
CEA
DX:
Strep Screen Conf.
DX:
Glucose
DX:
Urinalysis
DX:
HbgA1c
DX:
Urinalysis w/ Flex
DX:
Free T4
DX:
Urine Microalbumin
DX:
Ferritin
DX:
Vitamin D, 25
DX:
HDL
DX:
Urine Culture
DX:
Hepatic
DX:
CC CATH VOIDED
DX:
Culture of:
DX:
Iron
Lipase
DX:
Site:
Lipid Profile
DX:
Other Tests:
Magnesium
DX:
Potassium
DX:
Procalcitonin (PCT)
DX:
DX:
PSA(Diagnostic)
PSA(Screen)
DX:
T3
DX:
T4
DX:
Total Iron Bind.
DX:
Trig
DX:
TSH
DX:
Physician Signature: Date/Time:
Printed Physician Name:
Form # 701-001
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