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Body Fluid Cell Count and Differential

Laboratory : Hematology

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. Body Fluid Cell Count and Differential
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

FLC&D MSCOP

Specimen Type:

Cerebrospinal fluid; Body fluid

Tube Type:

Fluid Container

Collection Volume:

1.0 mL

Cause for Rejection:

Specimen more than 1 hour old, specimen grossly clotted

Storage:

Ambient

Availability:

Daily, 24 hours; STAT

Methodology:

Hemocytometer count and microscopic evaluation of Wright's stained cytocentrifuge preparation

Special Instructions:

Specify body fluid type

Lab/Phone:

330-746-9623

TAT:

1 hour

Additional Info:

Reference ranges available on patient report

CPT Code:

89051

Synonyms:

CSF Cell Count; Misc. Bodyfluid Cell Count

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