We are experiencing exceptionally high volumes in our emergency rooms.
Every patient is important to us, and we are doing all we can to provide care quickly and efficiently.

Glucose Peritoneal Dialysate

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. Glucose Peritoneal Dialysate
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

GLUPD/ACHM5

Specimen Type:

Peritoneal Dialysate

Tube Type:

sterile container

Collection Volume:

1 mL

Storage:

24 hours RT, 7 days Refrigerated, 30 days Frozen

Availability:

24 Hours/day, 7 days/week

Methodology:

Roche - UV Test

Special Instructions:

Deliver immediately to lab

Lab/Phone:

330-543-8417

TAT:

1 hour

CPT Code:

82945

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