Fillable H-3021 Test Request Form - H3021_dev

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H-3021 Test Request Form - H3021_dev

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U.S.A. forms for County of Los Angeles / Internal Services Department

BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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TEST REQUEST
Patient Name (Last, First) Date/Time Received Date/Time Reported
Submitter
Patient ID Number Race M F Date of Birth
Specimen Source Patient Location/Clinic Date/Time Taken
Requesting Physician /Referring
Laboratory
Submitter Accession #
Information for Viral Culture Information for Microbiological Exam
Date of onset:
PHN Code #:
Suspected virus:
Outbreak #:
Possible Child Abuse (Consult Laboratory)
Possible Medico-Legal Case (Consult Laboratory)
Aerobic Bacterial ID E. coli O157, Culture Malaria Confirmation
Aerobic Bacterial Culture E. histolytica EIA Microsporidium Exam
Specify: ________________________ Food – Specify: ____________________ N. gonorrhoeae Culture*
AFB, Amplified M. tuberculosis Fungal Culture and ID N. gonorrhoeae - NAAT
Direct Test Fungal Culture ID Ova and Parasite Exam
AFB, Culture for Identification Fungal ID, DNA Probe Pinworm Prep.
AFB, Smear “only”
Coccidioides immitis
Quantiferon
AFB, Smear, Culture and Susceptibility
Histoplasma capsulatum
Rabies Ag, DFA
AFB Susceptibility Hepatitis A Total Ab Respiratory Virus Culture
Anaerobic Bacterial ID Hepatitis A IgM Respiratory Pathogen PCR Panel
Anaerobic Bacterial Culture Hepatitis B Core Ab Rickettsial Ab Panel
Specify: ______________________ Hepatitis B Surface Ab Rotavirus Ag Detection
Arbovirus AB Panel Hepatitis B Surface Ag Salmonella Shigella Culture
Blood Smear, Parasite Exam Hepatitis C Virus Ab Shiga-like Toxin Screen
Bordetella Culture HIV-1/2 Ab Stool Culture – Specify _____________
Bordetella PCR HIV-1 Resistance, Genotyping Syphilis Reflex Panel
Campylobacter Culture HIV-1 Viral Load, PCR T. vaginalis, NAAT
C. trachomatis Culture HIV-1 Western Blot Vibrio Culture
C. trachomatis/N. gonorrhoeae HSV 1/2 PCR Viral Culture Comprehensive
Nucleic Acid Amplification Test HSV Culture Viral Identification
C. botulinum – Toxin HSV-2 IgG Ab West Nile Virus Ab
C. botulinum – Culture Influenza Virus A/B PCR Worm Identification
CMV Culture Lead, Blood Yersinia Culture
Cryptosporidium/Giardia DFA M. tuberculosis, Molecular Other:
Cryptosporidium/Cyclospora/Isospora Detection of Drug Resistance ________________________________
M. tuberculosis, PCR ________________________________
H3021 (01-14)
*a – For Legal cases or surveillance
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC HEALTH
PUBLIC HEALTH LABORATORY
TEST REQUISITION FORM
12750 ERICKSON AVENUE
DOWNEY, CA 90242
(562) 658-1300
FAX (562) 401
-
5999
California Certified Public Health Laboratory # 335637
CLIA #
05D1066369
Submitter Account #:
Account Information
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Completed 11 May 2020

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