Crystals
| 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. Crystals | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
CRYST
Test Workstation :
SUMMA
Specimen Type:
Any fresh body fluid
Tube Type:
Sterile container
Collection Volume:
1.0 mL
Minimum Volume:
0.5 ml
Storage:
Ambient
Availability:
Sent to reference lab
Methodology:
Microscopic Analysis
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range: Negative
CPT Code:
89060
