Clostridium difficile by Amplification

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. Clostridium difficile by Amplification
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

LAB3443

Specimen Type:

250mg (pea sized amount) of soft stool or 0.5 mL liquid stool in sterile container.

Cause for Rejection:

Formed stool, stool specimen sent on swab, diaper, or dried applicator stick, stool sent in any preservative or fixative.

Storage:

Refrigerated at 2-8C for <24 hours.

Availability:

Mon-Sun (08:00-15:00)

Methodology:

Nucleic acid amplification test for the detection of Toxigenic C. difficile.

Lab/Phone:

330-543-4863

TAT:

48 hours

CPT Code:

87493