KOH Preparation
| 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. KOH Preparation | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
KOH
Test Workstation :
MIC2
Specimen Type:
Skin, hair, or nails collected in sterile container.
Esophageal brush collected in sterile container with saline or sterile water.
Cause for Rejection:
Quantity not sufficient, improper specimen type, improper storage/transport, mislabeled, or unlabeled.
Storage:
Ambient
Availability:
Mon-Sun (0700-1600)
Methodology:
Microscopic exam
Lab/Phone:
330-543-8406
TAT:
24 hours
Additional Info:
Vaginal specimens are not accepted. Please order Gram Stain - Vaginal (LAB4167).
CPT Code:
87220
Synonyms:
Fungal Smear; Microscopic Exam for Fungus
