Fillable Test Request Form (State of North Dakota)

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Test Request Form (State of North Dakota)

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Test Request Form
701.328.6272 fax 701.328.6280 2/2021
www.ndhealth.gov/microlab
Patient Information
*Name: (Last) * (First) (M)
*Sex: Male Female
Race/Ethnicity:
*DOB (mm/dd/yyyy):
Specimen Information
*Collection Date:
*Type/Source:
Acute Convalescent
Facility Information
*Facility Name:
Address:
*Phone:
*Physician (Last, First Name):
*Facility
Code:
Patient Data
**Address:
**City/County:
**Phone:
State&Zip:
Hospitalization: Yes No
Care Facility: Resident Employee
Symptoms:
Test Request
MANDATORY REPORTABLE
CONDITION
Isolate: _____________________
BACTERIOLOGY
Aerobic Culture ID:
___________________________
Anaerobic Culture ID:
___________________________
Bordetella species HDA
Carbapenem Resistance Gene Screen
Gastrointestinal (GI) Panel
Legionella Culture
Rickettsia PCR
BIOTERRORISM RULE OUT
Agent Suspected:
___________________________
MYCOBACTERIOLOGY
Mycobacteria Culture (TB) & Smear
Mycobacteria TB complex /Rifampin
Screen (Requires Culture & Smear)
Mycobacteria Reference ID
Quantiferon (TB)
MYCOLOGY
Fungal Culture
Fungal Reference ID
PARASITOLOGY
Ova and Parasites
Giemsa Thick & Thin Blood Smears
HEPATITIS
Hepatitis A Antibody, IgM
Hepatitis A, B & C Panel
Hepatitis B & C Panel
Hepatitis B Core Antibody, IgM
Hepatitis B Core Antibody (Anti-HBC), Total
Hepatitis B Surface Antibody (Anti-HBs)
Hepatitis B Surface Antigen (HBsAg)
Hepatitis C Antibody (Anti-HCV)
Hepatitis C Virus Genotyping
Hepatitis C Virus RNA (Quantitative)
Prenatal Hep B Surface Antigen (HBsAg)
STD/SCREENING
Agglutination
VDRL (CSF)
VIROLOGY
Enterovirus PCR
Herpes Simplex/Varicella Zoster Virus HDA
Measles (Rubeola) Virus PCR
Mumps Virus PCR
Norovirus PCR
Respiratory Panel (RP2) PCR
SARS-CoV-2 (Novel Coronavirus COVID-19)
IMMUNOLOGY
Arbovirus Encephalitis Panel
Brucella Antibody
Encephalitis Panel
Francisella tularensis Antibody
Hantavirus Antibody, IgM
Herpes Simplex Virus Antibody IgM EIA
Lyme Disease Antibody EIA
Measles (Rubeola) Virus Antibody, IgG
Immune Screen
Measles (Rubeola) Virus Antibody, IgM
Mumps Virus Antibody, IgG Immune
Screen
Mumps Virus Antibody, IgM
Rubella Virus Antibody, IgG Immune
Screen
SARS-CoV-2 (Novel Coronavirus COVID-
19) IgG Immune Screen
TORCH Antibodies Panel, IgM
Varicella Zoster Virus IgG, Immune Screen
Varicella Zoster Virus Antibody, IgM
West Nile Virus EIA, IgM
ZIKA VIRUS
Trioplex (Zika, Dengue, Chikg) Virus
PCR* - must meet CDC criteria
Influenza Virus PCR
OTHER _______________________
*Required Field **Required Field for COVID19 tests
Chlamydia trachomatis/N gonorrhoeae
Fluorescent Treponemal Antibody
HIV-1, 2 Antibody/HIV-1 p24 Antigen Combo
RPR Syphilis
Syphilis Testing Panel
TP-PA: Treponema pallidum Particle
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Test Request Form (State of North Dakota)

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Completed 30 March 2021

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