Chlamydia/Gonorrhoeae Amplified RNA

Centralized Core Laboratory : Virology

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. Chlamydia/Gonorrhoeae Amplified RNA
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CGRNA/MAYO

Specimen Type:

Urine

Tube Type:

Sterile Urine Container

Collection Volume:

Refrigerated 20-50 mL random urine in sterile container

Cause for Rejection:

Unlabeled specimen, QNS, contaminated

Storage:

Refrigerated

Availability:

Sent to reference laboratory

Methodology:

Transcription Mediated Amplification

Special Instructions:

Collection Instructions: 1. Patient should not have urinated for at least 1 hour prior to specimen collection. 2. Patient should collect first portion of random voided urine (first part of stream) into a sterile, plastic, preservative-free container.

Lab/Phone:

330-543-8418

TAT:

1-4 days

CPT Code:

87591 and 87491

Panel Includes:

Chlamydia Amplified RNA and Gonorrhoeae Amplified RNA