Protein, Misc. fluid
| 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. Protein, Misc. fluid | |
| 2. | |
| 3. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
PROMF
Test Workstation :
ACHM1
Specimen Type:
Any fresh body fluid (pleural, synovial, drainages, etc)
Tube Type:
Fluid container
Collection Volume:
0.3 mL
Storage:
Refrigerated
Availability:
Daily, 24 hours; STAT
Methodology:
Biuret Reaction
Special Instructions:
Please specify type of body fluid. Deliver to lab immediately.
Lab/Phone:
330-543-8417
TAT:
8 hours
Additional Info:
Reference range: Not Established; Dr. interpretation only
CPT Code:
84155
