Mycoplasma pneumoniae, Qualitative PCR
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 pneumoniae, Qualitative PCR | |
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SPECIMEN INFO |
Collection Date & Time: |
Collected By: |
Hospital: |
Bronchoalveolar lavage (BAL)
Wash
Tracheal Aspirate
Cerebrospinal Fluid (CSF)
Swab: 1 Flocked Swab in 3.0 mL of M4 Viral Transport Medium
BAL, Wash, or Tracheal Aspirate: 2.0 mL collected in a Sterile Container (1.2 mL minimum)
Cerebrospinal Fluid: 1.0 mL collected in a CSF Tube/Container (0.2 mL minimum)
Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Improper Swab
Multiple Swabs per Vial of M4 VTM
Swab Not Present in M4 VTM vial
Swab Not Placed in M4 VTM Vial (Dry Swab)
Sample Exceeds Holding Time
Mpne