Mono-Screen
| 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. Mono-Screen | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
MSPOT
Test Workstation :
MIC1
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
0.5 mL
Cause for Rejection:
Any anticoagulant other than EDTA or heparin
Storage:
Refrigerated
Availability:
Daily
Methodology:
Immunochromatography for heterophile antibody
Special Instructions:
May be collected by fingerstick or venipuncture. Specimen types: Blood serum(red top), plasma(heparin) or whole blood(EDTA). Serum is preferred specimen.
Lab/Phone:
330-543-8412
TAT:
1-24 hours
Additional Info:
Reference range: Negative
CPT Code:
86308
Synonyms:
Mono Test
