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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:

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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Gram Stain Vaginal

Infectious Disease Laboratories : Microbiology

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