A/G Ratio
| 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. A/G Ratio | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
A/G
Test Workstation :
ACHM1
Specimen Type:
Blood
Tube Type:
Green top (lithium or sodium heparin)
Collection Volume:
1.5 mL
Storage:
Frozen
Availability:
Daily, 24 hours; STAT
Methodology:
Timed-endpoint colorimetric and Biuret reaction
Special Instructions:
If possible, patient should be recumbent for at least one hour prior to specimen collection.
Lab/Phone:
330-543-8417
TAT:
1 hour
Additional Info:
Reference range: 1.1-1.8
CPT Code:
84155
