Helicobacter Culture

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. Helicobacter Culture
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CLO MIC2

Specimen Type:

Gastric mucosal biopsy; Stomach tissue

Tube Type:

CLO Specimen container test slide

Collection Volume:

Small tissue sample obtained by physician

Cause for Rejection:

Excessive delay in transporting to laboratory

Storage:

Refrigerated

Availability:

Daily

Methodology:

Culture

Special Instructions:

Gastric tissue is inserted into test slide by physician at bedside or in surgery. The laboratory will supply test slides to physician upon request. Transport CLO test slide to laboratory immediately. Unused test slides should be stored in refrigerator and allowed to warm to room temperature before use. DO NOT FREEZE TEST SLIDES!

Lab/Phone:

330-543-8412

TAT:

24 hours

Additional Info:

CPT Code:

87081

Synonyms:

H. pylori Culture; Gastric Culture for H. pylori CLO Test