Gentamicin

Centralized Core Laboratory : Chemistry

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. Gentamicin
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

GENT MACH3

Specimen Type:

Blood

Tube Type:

Green top (lithium heparin) tube

Collection Volume:

1.5 mL

Storage:

Shipping- Send Refrigerated; Storage-Refrigerated: 1 week; Frozen: 4 weeks

Availability:

24 hours/day, 7 days/week

Methodology:

Roche-CEDIA

Special Instructions:

For therapeutic monitoring, draw peak levels 60 minutes after completion of parenteral (intramuscular or intravenous) administration and trough levels immediately prior to next dose. Please indicate whether the specimen is a peak, trough, or random level.

Lab/Phone:

330-746-9623

CPT Code:

80170

Synonyms:

Garamycin

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