pH, Gastric
| 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. pH, Gastric | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
PHGF
Test Workstation :
MMUA
Specimen Type:
Gastric fluid
Tube Type:
Sterile container - fresh gastric contents
Collection Volume:
2.0 ml (minimum 1.0 mL)
Minimum Volume:
1.0 mL
Preferred Volume:
2.0 mL
Storage:
Frozen
Availability:
Daily, 24 hours; STAT
Methodology:
pH paper
Lab/Phone:
330-746-9623
TAT:
1 hour
Additional Info:
Reference range: <2.0
CPT Code:
83986
