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.

Gram Stain Vaginal

Infectious Disease Laboratories : 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. Gram Stain Vaginal
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

GRAMV / MIC1

Specimen Type:

Vaginal swab or Vaginal washing

Tube Type:

Sterile Specimen container or Eswab

Collection Volume:

1 Eswab or 0.5 mL liquid specimen

Cause for Rejection:

Specimen sent in non-sterile container, specimen sent on dry swab

Storage:

Ambient

Availability:

Daily

Methodology:

Microscopic Examination

Lab/Phone:

330-543-8412

CPT Code:

87205

Specimen Collection Procedures:

Genital Specimen Collection

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