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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Glucose Peritoneal Dialysate

Centralized Core Laboratory : Chemistry

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