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: _____________
**Labs to be drawn at Mid Valley: Y /N
Office Phone Number: _____________________________ __________
ORDER DATE:________________________/TIME:____________________
Locations: AVP A/B ____ AMC A/B ___IMA ____ Mass/Kadison ____ Borchers ____ Comm. Health ____ Check ____ Locke Family ____ Other _________________
URINE TEST:
____ ABO/Rh
____ Heavy Metal (ryl blue/ EDTA)
CULTURES
____ UA CCMS Cath Peds
____ ANA
____ Iron TIBC ____
____ Strep A f/u culture
____ Urine Culture & Sensitivity
____ ANA (Comprehensive)
____ Lipase
____ Throat culture
____ Microalbumin, Urine
____ Alcohol
____ Lipid + LDL direct ____
____ Wound Culture:
____ GC/Chlam by PCR (AVH)
____ Amylase
____ LDH
Antibiotic Y
N
____ Urine Drug, Medical use / non-legal
____ Albumin (serum/plasma)
____ LH
____ Anaerobic/Aerobic Culture
____ ACTH
____ LipoProtein (a)
Antibiotic Y
N
STOOL TEST:
____ Bilirubin Total ___ Direct ___
____ Lithium
____ MRSA by PCR scrn
____ C. Diff STAT!
Indirect ___ Neonatal ___
____ Mg
Source of Culture:
____ WBC stool
____ BNP (Dr. Office, plasma frozen!)
____ Mercury, whole blood
____ Occ Blood
__________________________
____ BUN
(Ryl blue, EDTA)
____ O&P Comp (Mayo)
Serology:
____ B12 ____B12/Folic Acid
____ Methylmalonic Acid (serum)
(Giardia, E.Histolytica, Egg Cyst,
____ Strep B by PCR
____ CA 125
____ Malaria Test (wh bld) (EDTA)
Helminth eggs, Protozoa, Tape
____ B Pertussis
____ Valporic Acid / Depakote
____ Pregnancy Test, Qualitative
Worms, Larva worms)
____ RSV swab / nasal wash
Last dosage @ _____ Amt _______
Serum ___ Urine ___
____ Microsporidium only, Mayo
____ Flu
____ C-peptide
____ PSA, ( ___Scrn ____Diagn)
(MTBS)
____ Mono
____ Calcium (total) ____ Ionized, Calcium
____ PSA , Free & Total
____ Cyclospora only, MAYO (CYCL)
____ Sickle Cell Screen
____ CBC w auto ___ _ CBC w Manual
____ Progesterone
Panels:
____ CPK, Total
____ Prolactin
PANELS:
____ Chem13 (CMP)
____ Creatinine
____ K+ ( potassium)
____ Chem7 (BMP) (Renal)
____ Cholesterol
____ PT / INR Coumadin/Heparin
____ Gastrointestinal
____ Liver
____ CRP Inflammation ___ Cardiac ___
____ PTT
____ Respiratory Pathogen
____ Health Panel
____ Cortisol
____ Phosphorus
(CBC, Chem13, TSH)
____ D-Dimer STAT!
____ Protein Electrophoresis (serum)
24 Hour Urine (Circle one)
____Thyroid Panel
____ Digoxin
____ PIH panel
(T3U, T4, FTI)
Last dosage @ _____ Amt ________
(CBC, Chem13,Uric Acid)
Calcium
Creatinine Protein
____ Hepatitis, Acute (A,B,C)
____ Dilantin
____ RA Factor
Clearance
____ OB Panel
Last dosage @ _____ Amt ________
____ Rheumatoid Factor, Quant
Phosphorus
HIAA
Sodium
____ Arthritis Panel
____ Electrolytes
____ Retic Count
Chloride
Potassium Uric Acid
(RA, ESR, CRP-I,
____ Estradiol
____ RPR (Syphllis)
Uric Acid, ANA)
Other 24-Hour Urine test:
____ Ferritin
____ Sed Rate
____ DIC work up
____ FSH
____ Triglycerides
____ Maternal Quad Screen
________________________________
____ Folic Acid
____ Type/Screen
Other lab test: (Print)
____ GGT
____ Testosterone (total)
_________________________________
____ Glucose, Gestational
____ Testo (Free and Total)
__________________________
____ Glucose, Fasting Y _____ N ____
____ TSH
STANDING ORDER: YES
____ Glucose Tolerance Test 3 hr
____ Thyroid Antibodies
FREQUENCY:______________________
__________________________
____ Glucose, 2 hr Post eating
(TPO____, Globulin______)
*Good for 6 months only
____ HIV (consent signed in office Y / N )
____ Free, T4
____ T4 (total)
__________________________
____ Homocysteine
____ Free, T3
____ T3 (total)
SCHEDULER USE for ABNs
____ Herpes by PCR
____ T3, uptake
__________________________
____ HGbA1c
____ Troponin I STAT!
PASSED______ FAILED ______
____ HCG, Beta Quantitative
____ Uric Acid
__________________________
____ Hep C, Virus
____ Vit D (D2/D3) (Mayo)
FAILED TESTS:
____ Hep Bs AB ___ Hep Bs AG
____ Vit D (total)
__________________________
____ H. Pylori Igm, Igg (serum)
____ Vit D I, 25
____ Hematocrit ____ Hemoglobin
**Bold Italics test are
sent to Mayo
**Use Diagnosis Code(s) located on back of form
Laboratory Testing:
DS 100-L Revised: 05/2015
Reviewed by MR: 05/2015
Date Specimen Drawn: ______________ Time: ___________ Fasting: Yes ___ No ____