Cytomegalovirus (CMV), Qualitative PCR
| 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. Cytomegalovirus (CMV), Qualitative PCR | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Bronchoalveolar lavage (BAL)
Wash
Body Fluid
Synovial Fluid
Urine
Cerebrospinal Fluid (CSF)
Stool
Blood (plasma): 2 mL collected in a Purple Top- EDTA Tube (0.5 mL minimum)
BAL or Wash: 2.0 mL collected in a Sterile Container (1.2 mL minimum)
Body Fluid, Synovial Fluid, or Urine: 2.0 mL collected in a Sterile Container (0.2 mL minimum)
Cerebrospinal Fluid: 1.0 mL collected in a CSF Tube/Container (0.2 mL minimum)
Stool: 250mg (pea sized amount) of soft stool or 0.5 mL liquid stool in Sterile Container (125 mg soft stool or 0.2 mL liquid stool minimum)
Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Hemolyzed
Specimen Clotted
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Sample Exceeds Holding Time
CMVQL
