Aspen Valley Hospital Laboratory Scheduling/Client Form For Appointments: 970‐544‐1392 Fax 970‐544‐1589 PATIENT NAME:______________________________________________________ DOB:__________________________ SEX: M F HOME PHONE:_______________________ CELL PHONE:________________ INSURANCE:______________________________________________ NAME OF PHYSICIAN:__________________________________________ Physician Signature: ____________________________________________ (REQUIRED) Other Physician to receive copy of results: _________________________________________________ Bill Client _____________ Bill Insurance: _____________ Office Phone Number: _____________________________ __________ ORDER DATE:________________________/TIME:____________________ Locations: AVP ‐ A B AMC ‐ A B IMA Mass/Kadison Borchers Comm. Health Check Locke Family Other _________________ ____ ABO/Rh URINE TEST:
CULTURES
____ Iron Iron+TIBC+% Sat ____
____ Anaerobic/Aerobic Culture ____ UA ( CCMS Cath Peds Bag) ____ ACTH ____ LDH Antibiotic Y N ____ Urine Culture & Sensitivity ____ Alcohol ____ LH ____ MRSA by PCR scrn ____ Microalbumin, Urine ____ Albumin (serum/plasma) ____ Lipase ____ Strep A f/u culture ____ GC/Chlam by PCR (AVH) ____ Amylase ____ Lipid Panel +LDL direct ____ ____ Throat culture ____ Urine Drug, Medical use / non‐legal ____ ANA ____ LipoProtein (a) ____ Wound Culture ____ ANA (Comprehensive) ____ Lithium Antibiotic Y N STOOL TESTING: ____ Bilirubin Total ___ Direct ___ ____ Magnesium ____ Stool Culture Source of Culture: Indirect ___ Neonatal ___ ____ Malaria Test (wh bld ‐ EDTA) ____ B12 ____B12 + Folic Acid ____ Mercury, whole blood __________________________ ____ C. Diff ‐ STAT! ____ Norovirus Antigen (Frozen Stool) ____ BNP (from Office: FREEZE plasma!) (Ryl blue, EDTA) Serology: ____ Occult Blood ____ BUN ____ Methylmalonic Acid (serum) ____ B Pertussis ____ WBC’s – stool ____ CA 125 ____ Myoglobin, serum ‐ STAT! ____ Flu PARASITES: Countries pt. has visited in ____ Calcium (total) ____ Ionized, Calcium ____ Osmolality (both serum & rand. ____ Mono last 3 months = ____________________ ____ Cardiac Panel STAT! urine specimens required) ____ RSV (swab / nasal wash) (Troponin, Myoglobin) ____ O&P (AVH) Giardia & ____ Phosphorus ____ Sickle Cell Screen ____ CBC w/autodiff ___ CBC w/Man diff ____ Platelet Function Test (bl/lav) Cryptosporidium only ____ Strep B by PCR ____ Cholesterol, total ____ O&P Comp (MAYO ) ____ Potassium (K+) Panels: ____ Cortisol (Giardia, E.Histolytica, Egg Cyst, ____ Pregnancy Test, Qualitative ____ Chem13 Panel (CMP) ____ C‐peptide Helminth eggs, Protozoa, Tape Serum ___ Urine ___ ____ Chem7 Panel (BMP) ____ CPK, Total Worms, Larva worms) ____ Progesterone ____ DIC work up ____ Creatinine, plasma ____ Cryptosporidium only, MAYO ____ Prolactin ____ Health Panel (CRYPTOSP) ____ CRP Inflammation ___ Cardiac ___ ____ Protein Electrophoresis (serum) (CBC, Chem13, TSH) ____ D‐Dimer ‐ STAT! ____ PSA,total ____ Hepatitis Pnl, Acute (A,B,C) ____ Microsporidium only, MAYO (MICROSP) ____ Depakote/ Valporic Acid ____ PSA, Screen ____ Liver Panel ____ Cyclospora only, MAYO (CYCLOSP) Last dosage @ _____ Amt _______ ___ PSA, Diagnostic ____ Maternal Quad Screen ____ Digoxin ____ PSA , Free & Total ____ OB Panel 24 Hour Urine (Check one) Last dose @ _____ Amt ________ ____ PT / INR (Pt on: Coumadin Hep’n) ____ PIH panel Calcium HIAA ____ Dilantin ____ PTT (CBC, Chem13,Uric Acid) Phosphorus Potassium
Last dose @ _____ Amt ________ ____ RA Factor, qual. ____Thyroid Panel Chloride Protein
____ Electrolytes ____ Retic Count (T3Uptake, T4, FTI) Sodium Creatinine ____ Estradiol ____ Rheumatoid Factor, Quant ____ Thyroid Panel with TSH Clearance ____ Ferritin ____ RPR (Syphilis) Uric Acid
____ Arthritis Panel (ANA, ____ Folic Acid ____ Sed Rate Other 24‐Hour Urine test: RA, ESR, CRP‐I, Uric Acid) ____ FSH ____ Testosterone, total ____ GGT ____ Testosterone (Free and Total) ________________________________ Other lab test(s): (Print) ____ Glucose, Gestational ____ Triglycerides ____ Glucose Fasting? Y _____ N ____ ____ Troponin I ‐ STAT! _________________________________ __________________________ ____ Glucose Tolerance Test ‐ 3 hr ____ TSH STANDING ORDER: YES NO ____ Glucose, 2 hr Post eating ____ T3, free __________________________ ____ HCG, Beta , quantitative ____ T3, total FREQUENCY:______________________ ____ H&H (Hemoglobin & Hematocrit) ____ T3, uptake *Good for 6 months only __________________________ ____ Hematocrit ____ Hemoglobin ____ T4, free ____ Heavy Metal (ryl blue/ EDTA) ____ T4, total SCHEDULER USE for ABNs __________________________ ____ Thyroid Auto‐Antibodies ____ Hep C, Virus Antibody (TPO____, Thyroglob______) ____ Hep Bs AB ___ Hep Bs AG PASSED______ FAILED ______ __________________________ ____ Type and Screen ____ Herpes by PCR ____ Uric Acid ____ HgbA1c FAILED TESTS: __________________________ ____ Vit D (D2/D3 – to Mayo) ____ HIV (consent signed in office Y / N ) ____ Vit D (total) ____ Homocysteine _________________________________ **Tests in bold/italic ____ Vit D I, 25 dihydroxy ____ H. Pylori IgM, IgG (serum) are sent to Mayo _________________________________ *Use Diagnosis Code(s) located on page 2 Laboratory Testing: Date Specimen Drawn: ______________ Time: ___________ Fasting: Yes ___ No ___ LAB120 (Rev.09/2013) Page 1 of 2 Diagnosis (Check)
Diagnosis (Check)
ICD 9
ICD 10
Abd pain, generalized
789.07
R10.84
Drug Level, therap (pt/inr)
ICD 9
ICD 10
V58.83
Z51.81
Diagnosis (Check)
ICD 9
ICD 10
Pregnancy, supervision, high risk, 1 Trimester
V23.9
O09.91
V23.9
O09.92
V23.9
O09.93
st
Abd pain , RUQ
789.01
R10.11
Fabry’s disease (lipidoses)
272.7
E75.21
Pregnancy, supervision, high risk, 2nd Trimester
Abd pain, LUQ
789.02
R10.12
Fatigue/malaise
780.79
R53.83
Pregnancy, supervision, high risk, 3rd Trimester
Abd pain, RLQ
789.03
R10.31
Fertility test, sperm count
V72.40
Z31.41
Prostate Cancer
Abd pain, LLQ 789.04
R10.32
Fever
780.60
R50.9
PE acute, w/o cor pulmonale
Abd pain, periumbilical
789.05
R10.33
Gout
274.9
M10.9
PE acute with cor pulmonale
415.91
I26.09
Abd pain, epigastric
789.06
R10.13
Headache(s)
784.0
R51
PE, history of
V12.55
Z86.711
Z01.812
185
C61
415.91
I26.99
Acne
706.1
L70.9
Hematuria
599.70
R31.9
Preoperative Labs
V72.63
Anemia, normocytic
258.9
D64.9
Hemochromatosis
275.03
E83.119
Pulmonary Nodule
793.11
R91.1
Anemia, blood loss, chronic
280.0
D50.0
Hypercholesterolemia
272.0
E78.0
Renal insufficiency, acute
593.9 N28.9
Anemia, iron deficiency
280.9
D50.9
Anemia, blood loss, acute
285.1
D62
Hyperlipidemia
272.4
E78.5
Hypertension
401.9
I10
Anemia, due to chemo
285.3
Anemia, in neoplastic dz
285.22
D64.81
Hypertension, with heart fail
402.0
D63.0
Hypertension, with chr kidn dz
403.90
Anemia, in chronic kidney dz
285.21
D63.1
Asthma, unspec status
493.90
J45.909
Renal insufficiency, chronic
585.9
N18.9
Renal failure, acute
584.9
N17.9
I11.0
Renal failure, chronic
585.9
N18.9
I112.9
Renal failure, end stage
585.6
N18.6
Hyperthyroidism
242.9
E05.90
Rheumatoid Arthritis
714.0
M06.9
Hyperthyroidism, with goiter
242.00
E05.00
Routine Med Exam, normal
V70.0
Z00.00
Z00.01
Asthma, status asthmatic
493.91
J45.902
Hypothyroidism
244.9
E03.9
Routine Med Exam,abnormal
V70.0
Asthma, exacerbated
494.1
J45.901
Impotence
607.84
N52.9
Screening, CAD
V81.0
Z13.6
Atrial fibrillation, unspec
427.31
I48.91
Infertility, female
628.9
N97.9
Screening, Mammogram
V76.12
Z12.31
Atrial fibrillation, chronic
427.31
I48.2
Infertility, male
606.9
N46.9
Screening, Osteoporosis
V82.81
Z13.820
Blood typing
V72.86
Z01.83
Impotence
607.84
N52.9
Screening, PKU
V77.3
Z13.228
Breast Cancer, left
174.9
C50.912
Jaundice, fetal/neonatal
774.6
P59.9
Screening, Prostate
V76.44
Z12.5
Breast Cancer, right
174.9
C50.911
Jaundice, adult
782.4
R17
Shortness of Breath
786.05
R06.02
462
J02.9
Chest pain
786.50
R07.9
Leuk, lymph, acute, no remiss
204.00
C91.00
Sore Throat
Colon Cancer
153.9
C18.9
Leuk, lymph, acute, remission
204.01
C91.01
Syncope/collapse
780.2
R55
CHF, unspec (right heart)
428.0
I50.9
Leuk, lymph, chrnc, no remis
204.10
C91.10
Testicular Hypofunction
257.2
E29.1
CHF, left heart
428.1
I50.1
Leuk, lymph, chrnc, remiss
204.11
C91.11
Thyr goiter,not hyperthyroid
241.0
E04.1
CHF, systolic
428.20
I50.20
Leuk, lymph, Tcell, no remiss
204.80
C91.50
Tonsillitis – Step +
034.0
J03.00
CHF, diastolic
428.30
I50.30
Leuk, lymph, Tcell, remission
204.81
C91.51
Tonsillitis – acute
463
J03.90
CHF, combined
428.40
I50.40
Leuk, myel, acute, no remiss
205.00
C92.00
UTI
599.0
N39.0
Coronary Atheroscler, native
414.01
I25.10
Leuk, myel, acute, remission
205.01
C92.01
Vitamin B‐12 Deficiency
266.2
E53.8
Coronary Atheroscler, bypass
414.05
I25.810
Leuk, myel, chrnc, no remiss
205.10
C92.10
Vitamin D Deficiency
268.9
E55.9
Cough
786.2
R05
Leuk, myel, chrnc, remission
205.11
C92.11
DM Type II – controlled
250.00
E11.9
Long term use of Anticoag
V58.61
Z79.01
DM Type I – controlled
250.01
E10.9
Long term use of Antibiotics
V58.62
Z79.2
DM Type II – uncontrolled
250.02
E11.65
Long term use of NSAID
V58.64
Z79.1
DM Type I – uncontrolled
250.03
E10.65
Long term use of Aspirin
V58.66
Z79.82
Diabetes, Gestational
648.83
O24.419
Long term use of other med
V58.69
Z79.899
Diabetes, Gest,diet control
648.83
O24.410
Lung Cancer
162.9
C34.90
Diabetes, Gest,insul control
648.83
O24.414
Memory loss
780.93
R41.3
Diarrhea
787.91
R19.7
Menstruation, irregular 626.8
N92.6
Dizziness/vertigo
780.4
R42
DVT, acute, lower extremity
453.40
I82.409
Menstruation, DUB
626.8
N93.8
Menstruation, excessive
626.2
N92.0
DVT, acute, lower, right
453.40
I82.401
Multiple Sclerosis
340
G35
DVT, acute, lower, left
453.40
I82.402
Osteopenia
733.90
M85.9
DVT, acute, upper extremity
453.82
I82.629
Osteoporosis
733.00
M81.0
DVT, acute, upper right
453.82
I82.621
Pain, Back, Low
724.2
M54.5
DVT, acute, upper left
453.82
I86.622
Pain, Joint, knee
719.46
M25.569
DVT, history of
V12.51
Z86.718
Pain, Joint, shoulder
719.41
M25.519
Dysuria
788.1
R30.0
Pain, Neck
723.1
M54.2
Edema
782.3
R60.9
Pain, Rib
786.59
R07.82
157.9
C25.9
Elevated CRP
790.95
R79.82
Pancreas Cancer
Elevated/abnormal D‐Dimer
790.92
R79.1
Pharyngitis
Elevated/abnormal Liver level
790.6
R74.0
Pharyngitis – Strep +
462
J02.9
034.0
J02.0
Elevated/abnormal Mag level
790.6
R79.0
Polycythemia, vera
238.4
D45
Elevated/abnormal PT/PTT
790.92
R79.1
Polycythemia, secondary
289.0
D75.1
Elevated PSA
790.93
E97.2
Pregnancy, test
V72.40
Z32.00
Elevated Troponin level
790.5
R74.8
Pregnancy, in vitro supervision
V23.85
O09.819
Other Diagnoses:
This is page 2 of Aspen Valley Hospital’s Laboratory Scheduling/Client Form
Please make sure you submit both pages (tests requested and diagnoses).
LAB120 (Rev. 9/2013)
Page 2 of 2