DateSpecimenCollected TimeSpecimenCollected
Group/PracticeName
OrderingPhysicians AddressLine1
☐☐ AddressLine2
☐☐ City,StateZip
☐☐ Phone Fax
☐☐☐ Other
FirstName LastName MI DOB Gender
AddressLine1 AddressLine2 City State Zip
HomePhone CellPhone Race* Ethnicity*
Insured'sName RelationshiptoPatient SocialSecurity#
HomePhone CellPhone DOB Gender
PrimaryInsurance SecondaryInsurance
Group# ID# Group# ID#
Address Address
City State Zip City State Zip
OropharyngealSwabORNasopharyngealSwab:
RespiratoryPathogenPanelwithCOVID‐19(SARSCoV2Assay)
COVID‐19(SARSCoV2Assay)
J12.89Otherviralpneumonia A37.90Whoopingcough
J20.8Acutebronchitisduetootherspecifiedorganisms A48.1Legionnaires'disease
J22Unspecifiedacutelowerrespiratoryinfection B95.0GroupAStreptococcus
J80Acuterespiratorydistresssyndrome J02.0Streptococcalpharyngitis
R05Cough J02.9Pharyngitis,unspecified
R06.02Shortnessofbreath J06.9Acuteupperrespiratoryinfection,unspecified
R50.9Feverunspecified J11.1FluLikeSymptoms
Z20.828Contactwithandsuspectedexposuretootherviral Other___________________________________
communicabledisease Other___________________________________
RapidInfluenzaTestYesNoPositiveNegative
Rapid
StrepTestYesNoPositiveNegative
SignatureofPhysicianorOtherAuthorizedNPIProvider(REQUIRED) AccessionerInitials
_________________________________________________________________________________1__________ 2_________
*Race
andEthnicityarerequiredbycertainstatesandtheCDC **Seereversesidefordetails
Pleaseindicatewhetherarapidinfluenzatestorarapidstreptestwasperformedintheofficetoday
COVID19CODESARELISTEDBELOWANDMUSTBECHECKEDOFF
RespiratoryRequisition
LaboratoryUseOnly
PracticeContactInformation
AccessionNumber
PatientandInsuranceInformation
(CurrentlyNotAcceptingMedicaidorManagedMedicaidPlans‐ContractPending)
ICD10Codes
TestPanels
DateReceived TimeReceived
ThroatSwab:
GroupAStreptococcus
UpperRespiratoryPanel
ICD10Codesarelistedforinformationpurposesonly.Itistheprovider'sresponsibilitytoorderteststhataremedicallynecessaryandinthebestinterestofthepatient.
1912 Rt 35 S, Ste 203, Oakhurst, NJ 07755
P: 732-389-1530 IF: 732-389-0352 I Courier P: 732-508-9154
.labofchoice.com
GLM Expanded Respiratory Panel
Bacteria
Bordetella (parapertussis, bronchiseptica)
Bordetella pertussis
Chlamydophila pneumoniae
Haemophilus Influenzae
Klebsiella pneumoniae
Legionella pneumoniae
Mycoplasma pneumoniae
Streptococcus pneumoniae
Staphylococcus aureus
Viruses
Adenovirus
Bocavirus
Coronavirus 229E
Coronavirus HKU1
Coronavirus NL63
Coronavirus OC43
Enterovirus
HHV3 (Varicella Zoster Virus)
HHV4 (Epstein Barr Virus)
HHV5 (Cytomegalovirus)
Influenza A H1-2009
Influenza A H3
Influenza A pan
Influenza B
Parainfluenza Virus 1
Parainfluenza Virus 2
Parainfluenza Virus 3
Parainfluenza Virus 4
Respiratory Syncytial Virus (RSV) A
Respiratory Syncytial Virus (RSV) B
Rhinovirus
Fungal Target
Pneumocystis jiroveci
Focused Viral Panel
Influenza A
Influenza B
Respiratory
Syncytial Virus (RSV)
Group A Streptococcus
Streptococcus pyogenes
SARS-CoV-2 / COVID 19
PLEASE NOTE: The Thermo Fisher TaqMan 2019-
nCoV Assay Kit v1 and TaqMan 2019-nCoV Control
Kit v1 Test and/or TaqPath COVID-19 Combo Kit is
indicated as an aid in the diagnosis of specific
agents of respiratory illness and results are meant
to be used in conjunction with other clinical,
laboratory, and epidemiological data. Positive
results do not rule out co-infection with organisms
not included in the Thermo Fisher TaqMan 2019-
nCoV Assay Kit v1 and TaqMan 2019-nCoV Control
Kit v1 and/or TaqPath COVID-19 Combo Kit. The
agent detected may not be the definite cause of
this disease.
A Positive result indicates the presence of SARS-
CoV-2 RNA but does not exclude bacterial infection
and/ or coinfection with other viruses. The agent
detected may not be the definitive cause of
disease. This result should be combined with
clinical observation, patient history, and
epidemiological information for patient
management decisions.
Negative results do not preclude SARS-CoV-2
infection and should not be used as the sole basis
for treatment and other patient management
decisions. Negative results must be used in
conjunction with clinical observation, patient
history, and epidemiological information for
patient management decisions.
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