MEDICAL
TEST REQUISITION
PHONE: (866) 647-2847
(317) 856-2681
FAX: (317) 856-3685
ORDERING FACILITY
Facility Name:
Customer ID:
Address:
City
State/ZIP
Laboratory Contact:
Phone #:
E-mail:
FAX #:
PATIENT INFORMATION
Last
First
Date of Birth: MM/DD/YYYY
/
Ordering Physician Name:
Specimen Collection Date: MM/DD/YYYY
319
317
Cryptococcus
Antigen, Latex
Agglutination
SER
CSF
324
Blastomyces
Antibody by
Immunodiffusion
SER
Coccidioides
Antibody by
Immunodiffusion
SER
Histoplasma
Antibody by
Immunodiffusion
SER
Aspergillus Antibody
by Immunodiffusion
 Refrig
 Frozen
 Refrig
 Frozen
SER
 Refrig
 Frozen
Test Code
Specimen
Storage
 Refrig
 Frozen
321
Aspergillus Antibody
IgG, EIA
please circle
SER
THERAPEUTIC DRUG MONITORING
(13) β-D Glucan
Colorimetric Assay
320
please circle
Accession #
& Specimen Type
 Refrig
 Frozen
MVista®
Histoplasma
Quantitative Antigen
SER UR BAL CSF
Other:
EIA
Refrig  Refrig
Frozen  Frozen
SER UR BAL CSF
Other:
322


MVista® Coccidioides
Quantitative Antigen
EIA
SER UR BAL CSF
Other:
Test Name
 Refrig
 Frozen
310
MVista®
Blastomyces
Quantitative
Antigen EIA
323
 Refrig
 Frozen
315
SER BAL CSF*
Other:
 Refrig
 Frozen
316
Aspergillus
Antigen EIA
please circle
SER
CSF*
 Refrig
 Frozen
Test Code
309
please circle
Accession #
& Specimen Type
Specimen
Storage
/
/
ANTIBODY DETECTION
ANTIGEN DETECTION
Test Name
/
312
MVista® Itraconazole
by BioAssay
SER Plasma
 Refrig
 Frozen
Patient Name:
*validated at MiraVista Diagnostics
Due to HIPAA regulations, results will only be sent to the FAX number(s) listed above.
Invoices will be sent to Facility detailed above. WE DO NOT BILL PATIENTS or INSURANCE.
For specimen handling requirements, turn around time, and hours of operation, visit www.miravistalabs.com
V072914
MiraVista Diagnostics
4705 Decatur Blvd., Indianapolis, IN 46241

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