Neonatal CMV Screen

Molecular Diagnostics : DNA

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. Neonatal CMV Screen
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CMVNE/DNA2

Specimen Type:

Urine

Tube Type:

Urine container

Collection Volume:

0.5 mL

Storage:

Refrigerated

Availability:

Mon-Fri

Methodology:

Polymerase Chain Reaction (PCR)

Special Instructions:

Testing for patients <= 4 weeks of age ONLY.

Lab/Phone:

330-543-8722

TAT:

24-72 hours

Additional Info:

Reference Range: NEGATIVE: No CMV DNA detected.

CPT Code:

87496

Synonyms:

CMV PCR Cytomegalovirus PCR

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