Calculus Analysis
| 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. Calculus Analysis | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
CALCU
Test Workstation :
MAYO
Specimen Type:
Entire Stone
Tube Type:
Clean container
Collection Volume:
Entire kidney stone
Cause for Rejection:
Embedded in tissue, sent with collection devices, sent in fluidfilled containers, or sent with significant nonstone debris. Source other than renal.
Storage:
Ambient
Availability:
Sent to reference lab
Methodology:
Infrared Spectrum Analysis
Special Instructions:
Specimen Source is required. Specimen must be sent clean and dry.
Lab/Phone:
330-543-8418
TAT:
2-4 days
Additional Info:
Reference range is available on patient report
CPT Code:
82365
