Chlamydia/Gonorrhoeae Amplified RNA
| 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. Chlamydia/Gonorrhoeae Amplified RNA | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
CGRNA
Test Workstation :
MAYO
Specimen Type:
Urine
Tube Type:
Sterile Urine Container
Collection Volume:
Refrigerated 20-50 mL random urine in sterile container
Cause for Rejection:
Unlabeled specimen, QNS, contaminated
Storage:
Refrigerated
Availability:
Sent to reference laboratory
Methodology:
Transcription Mediated Amplification
Special Instructions:
Collection Instructions:
1. Patient should not have urinated for at least 1 hour prior to specimen collection.
2. Patient should collect first portion of random voided urine (first part of stream) into a sterile, plastic, preservativefree container.
Lab/Phone:
330-543-8418
TAT:
1-4 days
CPT Code:
87591 and 87491
Panel Includes:
Chlamydia Amplified RNA and Gonorrhoeae Amplified RNA
