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REFERRING CLIENT/COLLECTION CENTER
(VPLS) VPLS CLIENT ACCOUNT
VANDERBllT PATHOLOGY LABORATORY SERVICES
Nashville:
(615) 936-0510
•
(800)551-5227
Continental U.S.:
BILL TO:
SEND SPECIMEN(S) TO:
Client Account
4607 The Vanderbilt Clinic
1301 Medical Center Drive
Patient (Billing information must be attached .)
Nashville TN 37232-5310
PATIENT NAME (LASn
REFERRING PHYSICIAN
(M.I.)
(FIRSn
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SEX
FEMALE
0 MALE
DATE COLLECTED
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SERUM 0
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PLASMA 0
DATE OF BIRTH
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URINE 0
~:I
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REQUEST #
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SAMPLE ID
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3G
L..._ _ _ _ _ _ _---l(REFERENCEJ
OTHER
URINE TOTAL VOLUME
Referring Physician:,_ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Referring Laboratory:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Con~ctPerson :
FOR LAB USE ONLY
3G MR#
3G
L..._ _ _ _ _ _ _ _--l(CLIENn
TIME COLLECTED
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PATIENT ID NUMBER
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PHONE NUMBER
Phone:.____________________
Phone: _ _ _ _ _ _ _ _ _ _ __
Fax: _ _ _ _ _ _ _ _ _ _ ___
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Vanderbilt Medical Record # (if known): _ _ _ _ _ _ _ _ _ _ _ __
ICD-9 Code:
Diagnosis:
-
-
BMP
CMP
HPF
LIP
RNL
CBP
CPD
RET
_ABL
DOL
_ALT
_AST
- B2M
- BNP
- CA
- CK
- CRE
- FER
- FS
- FSH
- GGT
- GLU
- B27
FE
LDH
- LP
- MG
- K
PTI
_TST
FT4
- TRF
- TSH
BUN
- UAB
B12
_VC
_TVD
CHEMISTRY PANELS
BASIC METABOLIC PANEL (MINT)
COMP METABOLIC PANEL (MINT)
HEPATIC FUNCT. PANEL (MINT)
LIPID / HDL PANEL (MINT)
RENAL FUNCTION PANEL (MINT)
HEMATOLOGY TESTS
CBC / PLATELET COUNT (PURP)
CBC/PLATELET CT/DIFF (PURP)
RETICULOCYTE COUNT (PURP)
CHEMISTRY TESTS
ALBUMIN (MINT)
ALDOLASE (RED)
AL T (SGPT) (MINT)
AST (SGOT) (MINT)
BETA-2 MICROGLOBULIN (RED)
B - NATRIU. PEPTIDE (BNP) (PURP)
CALCIUM (MINT)
CREATINE KINASE (MINT)
CREATININE BLOOD (MINT)
FERRITIN (MINT)
FOLATE (MINT)
FOLLICLE STIM HORMONE (MINT)
GAMMA GLUT TRANS (GGT) (MINT)
GLUCOSE (MINT)
HLA B27
IRON (MINT)
LDH (MINT)
LIPASE (MINT)
MAGNESIUM (MINT)
POTASSIUM (MINT)
PTH, INTACT (RED)
TESTOSTERONE (MINT)
THYROXINE , FREE (FR T4) (MINT)
TRANSFERRIN (RED)
THYROID STIM HORM (TSH) (MINT)
UREA NITROGEN (BUN) (MINT)
URIC ACID (MINT)
VITAMIN B1 2 (MINT)
VITAMIN C (MINT)
VITAMIN D25-0H (MINT)
DIG
PNB
_PHY
- FPH
THE
_VAL
-
_ACI
_APA
- HYC
- LAS
- LUP
- CAC
- PS
- PCA
- SAT
- SAF
- PT
- PTT
RCC
RW
_TT
_VWI
DNA
_AMA
_ANA
ANP
_ANC
- MPO
PR3
_ASO
BBT
- CRP
- CRH
- CCP
- C3
- C4
- CSO
- ELU
- SI
- RF
RPR
SMA
-
or
ICD-10 Code:
THERAPEUTIC DRUG lEVELS
DIGOXIN (DARK GN)
PHENOBARBITAL (DARK GN)
PHENYTOIN (DARK GN)
FREE PHENYTOIN (DARK GN)
THEOPHYLLINE (DARK GN)
VALPROIC ACID (DARK GN)
COAGULATION TESTS
ABNORMAL PT/PTT EVAL (IT Bl)
ANTICARDIOLIPIN ABS (IT Bl)
HYPERCOAG PANEL (LTBL)(PURP)
LUPUS ANTICOAG ST-LA (IT Bl)
LUPUS ANTICOAG PROF. (LT Bll
PROTEIN C ACTIVITY (IT Bll
PROTEI N S ACTIVITY (LT Bl)
PROTEIN C ANTIGEN(LT Bll
PROTEIN SAG TOTAL (LT Bl)
PROTEIN SAG FREE (LT Bl)
PT/INR (IT Bl)
PTT (LTBL)
RISTOCETIN COFACTOR (IT Bl)
RUSSELL VIPER VENOM (LT BL)
THROMBIN TIME (LT BL)
VONWILLIBRAND EVAL (IT BL)
IMMUNOLOGY TESTS
ANTI-DNA (ds) (RED)
ANTIMITOCHONDRIAL AB (RED)
ANTINUCLEAR AB (RED)
SPECIFIC ANA PROFILE (RED)
ANTI NEUTRO CYTO AB (RED)
ANTI MYELOPEROXIDASE (RED)
ANTI PROTEINASE 3 (RED)
ANTI STREPTOLYSIN 0 (RED)
BORRELIA AB (LYME) (RED)
C-REACTIVE PROTEIN (MINT)
HIGH SENSITIVITY C-RP (MINT)
CCP ANTIBODY IGG (RED)
COMPLEMENT C3 (MINT)
COMPLEMENT C4 (MINT)
CHSO (RED)
ELECTROPHORESISIIFX UR
ELECTROPHORESISIIFX BL(RED)
RHEUMATOID FACTOR (RED)
RPR (RED)
SMOOTH MUSCLE AB (RED)
_BF
_SYN
CRU
=SPU
_PRU
_TUA
_UA1
_BAB
_MSB
_GS
_URB
_BFF
_ABA
_HAV
_HBC
_HBM
_HBS
_HBG
_HCV
_HIV
URINE / BODY FLUIDS BODY FLUID EXAM Fluid type: ___________
SYNOVIAL FLUID EXAM Fluid type:._ _ _ _ __
CREATININE URINE PROTEIN URINE SPOT PROTEIN 24HR URINE URIC ACID 24HR URINE
URINALYSIS MICROBIOLOGY TESTS
BLOOD CULTURE
CULTURE & SENSITIVITY
Source:--=-:...,.,...,-________
GRAM STAIN
URINE CULTURE & SENSITIVITY
FUNGUS CULTURE
Source : AFB C U"""LT=U-:":R::":E:-&:--::'"SM:-:'E=-A:"":R=-­
Source:___________
HEPATITIS / HIV TESTS
HEPATITIS A AB PROFilE (RED)
HEPATITIS B CORE TOT AB (RED)
HEPATITIS B CORE IGM (RED)
HEPATITIS B SURFACE AB (RED)
HEPATITIS B SURFACE AG (RED)
HEPATITIS CAB (RED)
HIV 1&2 AB / P24 AG SCRN (RED)
OTHER TESTS
please write in testIs) requested:
STAT - call results to:
e Vanderbilt University Medical Center
FOR MORE INFO: WWW.LABVU.COM
VPLS: 1-800-551-5227
FORM NO. 60-002-664 (REV 07/10)