Adenovirus, Qualitative PCR
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Adenovirus, Qualitative PCR | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Swab
Lesion
Conjunctiva
Bronchoalveolar lavage (BAL)
Wash
Tracheal Aspirate
Body Fluid
Urine
Synovial Fluid
Cerebrospinal Fluid (CSF)
Stool
Blood (plasma): 2 mL collected in a Purple Top- EDTA Tube (0.5 mL minimum)
Swab, Lesion, or Conjunctiva: 1 Flocked Swab in 3.0 mL of M4 Viral Transport Medium
BAL, Wash, or Tracheal Aspirate: 2.0 mL collected in a Sterile Container (1.2 mL minimum)
Body Fluid, Urine, or Synovial Fluid: 2.0 mL collected in a Sterile Container (0.2 mL minimum)
Cerebrospinal Fluid: 1.0 mL collected in a CSF Tube/Container (0.2 mL minimum)
Stool: 250mg (pea sized amount) of soft stool or 0.5 mL liquid stool in Sterile Container (125 mg soft stool or 0.2 mL liquid stool minimum)
Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Hemolyzed
Specimen Clotted
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Improper Swab
Multiple Swabs per Vial of M4 VTM
Swab Not Present in M4 VTM vial
Swab Not Placed in M4 VTM Vial (Dry Swab)
Sample Exceeds Holding Time
ADNQL
