VMA
| 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. VMA | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
VMA
Test Workstation :
MAYO
Specimen Type:
Urine
Tube Type:
Urine container
Collection Volume:
24 hour urine collection
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Special Instructions:
5.0 mL from a wellmixed 24 hour urine collection. Refrigerate specimen during collection. Instruct patient on 24 hour urine collection. To begin the urine collection, have the patient void. DISCARD THIS URINE SPECIMEN. This is best done with the first morning specimen. Note the time and record on the requisition. From then on collect all the urine that is voided and place in container. If more than one container is needed, please mark the first as #1 of 2 and retain on the floor until the collection is complete. The final void should be made 24 hours after the first void described earlier. The specimen should be included with the collection. Once the specimen is received in the lab, add 25 mL (15 mL if patient < 5 years old) of 50% acetic acid as preservative.
THIS TEST IS FOR 24HR COLLECTIONS ONLY. FOR RANDOM SAMPLES PLEASE ORDER ON A MANUAL REQUISITON.
Lab/Phone:
330-543-8418
TAT:
2-4 days
Additional Info:
Ref. range is age dependent; available on patient report. Bactrim may interfere with detecton of the analyte.
CPT Code:
84585
