Public Health Laboratory
County of Santa Clara
2220 Moorpark Ave.,2nd Fl., San Jose, CA 95128
(408) 885-4272 FAX (408) 885-4275
Patricia A. Dadone, Laboratory Directo
LAB NUMBE
DATE/TIME
LIA N
.: 05D0643967
NPI N
: 152816588
INFORMATION BELOW MUST BE PROVIDED BEFORE REQUISITION WILL BE PROCESSED
Patient Name (Last) (First) (M) Sex Date of Birth (DOB)
Address Street City State Zip
Patient Telephone Number Patient ID Number Medical Record Number Submitting Laboratory's Specimen ID Number
Date Specimen Taken Date of Onset Next CHDP Visit
Patient History/
Travel History
Reason For Testing
Contact
Clearance
Screen
Immunity Status
Other
Type of Specimen
Blood
CSF
Urine Cervix Rectal Urethral Throat Feces
Serum
Wound
Sputum Gastric
Skin
Plasma (Heparin)
Naso-Pharyngeal
Name (physician's name) UPIN #
ICD-9 code (diagnosis code required)
Responsible Party
Relationship (circle one)
Self
Spouse Child Other
Name
ddress Street City Zip
ddress
Responsible Person: Telephone
City
Telephone
Bill to / Insurance Number:
Submitter Medi-Cal Blue Cross - Medi-Cal Medicare
CHDP VHP
CCAH
Other
Fax
Contact
Check Test Bein
Ordered and Source
BACTERIOLOGY: VIROLOGY: MOLECULAR TESTING:
LABORATORY USE ONLY
COMPLETE INFORMATION & A COPY OF INSURANCE CARD
MUST BE ATTACHED OR SUBMITTER WILL BE BILLED
ORDERING PHYSICIAN INFORMATION
Social Security No. (SSN)
Zip
State
SUBMITTER INFORMATION
IMPRINT PLATE OR INPUT MANUALLY
[ ] Respiratory Panel Culture [ ] Gonorrhea - molecular method
[ ] Respiratory Panel - direct smear [ ] Cervix
[ ] Chlamydia - direct smear [ ] Urethra
[ ] Cervix [ ] Urine
Cervix
Pharyngeal
[ ] Rectal
[ ] Urethra
[ ] Eye [ ] Pharyngeal
[ ] Gonorrhea Culture
[ ] Rectal
[ ] Rectal
[ ] Pharyngeal
[ ] Throat
[ ] Chlamydia - molecular method
[ ] Rectal
[ ] Urethra
[ ] Cervix
[ ] Urine Culture
[ ] Herpes 1/2 DFA
[ ] Urethra
[ ] B. pertussis DFA [ ] Urine
[ ] B. pertussis culture VIRAL SEROLOGY
(red or tiger top): [ ] Pharyngeal
[ ] MRSA [ ] HBsAg [ ] Rectal
[ ] Streptococcus (Strep A)
[ ] HBcore Total [ ] Bordetella pertussis
[ ] Enteric culture (primary stool) [ ] HCV [ ] Influenza (A/B)
Salmonella / Shigella / E. coli O157 (
circle one) [ ] HIV (serum) [ ] Influenza subtyping
[ ] Shiga-Toxin Immunoassay [ ] HIV (oral fluid ) [ ] Avian Influenza
[ ] Measles IgG
[ ] Norovirus
SEROLOGY:
[ ] Measles IgM
[ ] Measles
[ ] RPR
(red or tiger top)
[ ] Herpes 1/2 IgG
[ ] Mumps
[ ] previous positive [ ] West Nile Virus [ ] Dengue
[ ] TPPA
[ ] Darkfield microscopy PARASITOLOGY: MYCOLOGY
[ ] Ext. genitalia [ ] Ova and Parasites [ ] Fungal culture
[ ] Int. genitalia [ ] Pinworm [ ] Yeast culture
[ ] Oral [ ] Cryptosporidia
[ ] Helminth identification SPECIAL TEST REQUEST(S)
MYCOBACTERIOLOGY / TB: [ ] Arthropod identification
[ ] Quantiferon-TB Gold In-Tube Assay [ ] Blood film [ ]
[ ] NAAT - GenXpert
[ ] Malaria speciation
[ ] Culture
[ ] B. burgdorferi (tick ID & test)
[ ] Sensitivities (1st line drugs)
CHEMISTRY/ TOXICOLOGY:
[ ] Blood Lead - capillary screen
[ ] Molecular Beacon
[ ] Pyrosequencing
revised 10/6/2020
[ ] Blood Lead - venous confirmation
Covid-19 PCR
Other
Gonorrhea Smear
Submit form with sample to Public Health Lab
