Urinalysis, Complete
| 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. Urinalysis, Complete | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
UACOM
Test Workstation :
MAUA1
Specimen Type:
Urine
Tube Type:
Urine Container
Collection Volume:
12.0 mL
Minimum Volume:
1.0 mL
Preferred Volume:
12.0 mL
Cause for Rejection:
Specimen leaking from container, excessive delay in transport
Storage:
Refrigerated
Availability:
Daily, 24 hours; STAT
Methodology:
Siemens Multistix Strips with a manual urine microscopic
Special Instructions:
12.0 mL of urine is the preferred volume. Stable 24 hours refrigerated.
Lab/Phone:
330-746-9623
TAT:
1 hour
Additional Info:
Reference ranges available under individual tests
CPT Code:
81001
