Mycoplasma Culture
| 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. Mycoplasma Culture | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
MYPLA
Test Workstation :
CLEVE
Specimen Type:
Cervical, Endocervical, Urethral, Vaginal swab, Urine, or Semen
Tube Type:
M4 Viral Transport Medium (VTM)
Collection Volume:
Genital swab in M4 VTM, 1 mL urine or semen in M4 (VTM)
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Culture
Special Instructions:
Transport medium must be inoculated at the point of collection. M4 VTM can be obtained from the Virology Laboratory 3305438576 or the Centralized Core Laboratory if after 4:00 p.m. at 3305438418
Lab/Phone:
330-543-8418
TAT:
10 days
Additional Info:
Reference Value: Negative for M. hominis or U. urealyticum
CPT Code:
87109
