Sequential Screen, First Trimester
| 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. Sequential Screen, First Trimester | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
SEQ1
Test Workstation :
GENZY
Specimen Type:
Blood
Tube Type:
Gold top SST (Serum Separator tube, no anticoagulant)
Collection Volume:
2.0 mL
Minimum Volume:
1.0 mL
Storage:
Refrigerated
Availability:
Sent to Reference lab
Methodology:
Enzyme Linked Immunoassay (ELISA)
Special Instructions:
Patient's gestation age required
Lab/Phone:
330-543-8418
TAT:
2-3 days after specimen received in reference lab
Additional Info:
Reference range is available on patient report
CPT Code:
84163, 84702
Panel Includes:
PAPP-A
HCG, Qnt
