Specific gravity

Laboratory : Urinalysis

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. Specific gravity
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

SPGRU MAUA1

Specimen Type:

Urine

Tube Type:

Urine container

Collection Volume:

12.0 ml(minimum 0.5 mL)

Cause for Rejection:

Specimen leaking from container, excessive delay in transport

Storage:

Refrigerated

Availability:

Daily, 24 hours; STAT

Methodology:

Refractometry

Special Instructions:

Transport specimen to the lab within 2 hours. Stable 4 hours refrigerated.

Lab/Phone:

330-746-9623

TAT:

1 hour

Additional Info:

Reference range is available on patient report

CPT Code:

81003

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