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OB-GYN

Fax Order Form / Step 1. Ordering PhysicianPhysician

Follow Steps 1-5 for a complete order. Fax orders to 574-807-3010 or 1-866-674-5138

Step 2. DemographicsPatient Name
DOB SS# / Step 3. Frequency or Add-on to Existing Specimen
One time draw: date (if needed)
Standing order (Note: Standing orders are valid for one year.)
Add-on: Date of draw

Step 4. Mark Tests Needed Step 5. List Diagnosis (DX) or ICD-9 Code For Each Test

031021-4 2/09 lsh

031021-4 2/09 lsh

Panel Tests / DX
29048 / Lipid Panel
29526 / Metabolic Basic Panel
29527 / Metabolic Comprehensive Panel
35839 / Obstetric Panel
29522 / Pre-Eclamptic OB Panel
29528 / Renal Function Panel
Individual Tests / DX
22000 / ABO/Rh Typing
29039 / Calcium
25517 / CBC with Diff
25014 / CBC without Diff
30181 / CEA
30123 / DHEA-S
30085 / Estradiol
30055 / Ferritin
30093 / FSH
30016 / FT3
30113 / FT4
/ Individual Tests / DX
29129 / Glucose (Fasting)
29004 / Glucose 50 gm Challenge
29057 / Glucose Tolerance, Gest
28183 / HBsAg
30089 / HCG, Qualitative
30079 / HCG, Qual & HCG Quant if indicated
30088 / HCG, Quantitative
28031 / HDN Antibodies
23409 / Hemoglobin A1C
28131 / HIV-1/2 Ab Screen w/WB if ind
29100 / Iron includes (TIBC)
30096 / LH
23084 / Magnesium
30200 / Progesterone
30097 / Prolactin
23119 / Protein, Total
25045 / Prothrombin Time (PT)
28090 / Rh Imm Prevention Pn
/ Individual Tests / DX
28036 / Rubella (IgG)
25230 / Sed Rate
25060 / Sperm Anyl w/Morph
28244 / STS
30101 / Testosterone, Total
30017 / TSH
25074 / UA w/Micro. C&S if ind
30091 / AFP Maternal
30180 / Prenatal Risk Quad
30080 / Prenatal Risk Triple
45316 / Prenatal Risk, Integrated, 1st Specimen
30082 / Prenatal Risk, Integrated, 2nd Specimen
EDD Wt.
Fetus Race
Insulin (Y/N)
Repeat Spec (Y/N)
36050 / Cystic Fibrosis
Race
Indication
Family Hx
Additional Tests / DX
Optional Stat Phone Fax
Copy to
Special Instructions:
Fasting?

Faxed by Date/Time

031021-4 2/09 lsh