Gram Stain

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
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

GRAM

Test Workstation :

MIC1

Specimen Type:

E-swab or smear from specimen for bacterial culture.

Cause for Rejection:

Quantity not sufficient, improper specimen type, improper storage/transport, improper swab, dry swab, multiple swabs per vial, mislabeled, or unlabeled.

Storage:

Refer to storage conditions for related cultures.

Availability:

Mon-Sun (0700-1600)

Methodology:

Microscopic examination

Lab/Phone:

330-543-8406

TAT:

24 hours

Additional Info:

Gram stains are automatically added to all CSF, Aerobe, Wound, Sputum, and Tracheal aspirate cultures and do not need to be ordered separately.

CPT Code:

87205

Synonyms:

Bacterial Stain; Direct Stain for Bacteria

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Gram Stain

Infectious Disease Laboratories - : Microbiology

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