Environment Culture

Laboratory - : Microbiology

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. Environment Culture
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

ENVIR

Test Workstation :

MMIC2

Specimen Type:

Equipment Swab, Formula, Water, Autoclave strips

Tube Type:

Specimen container

Collection Volume:

5.0mL fluid (minimum 1.0mL or swab)

Cause for Rejection:

Specimen collected in nonsterile container

Storage:

Refrigerated

Availability:

Daily

Methodology:

Culture

Special Instructions:

Use Eswab to culture equipment. For fluid samples such as formula or dialysis water, please send at least 5.0mL for testing. Deliver to laboratory as soon as possible.

Lab/Phone:

330-746-9623

TAT:

48 hours

CPT Code:

87084

Synonyms:

Autoclave Culture; Respiratory Care Culture

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Environment Culture

Laboratory - : Microbiology

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