Download LABORATORY DIRECT ACCESS TESTING

Collection Date: _____/_______/_____
Waiver Signed?
Yes
Time:__________________
No
Checked By:
LABORATORY DIRECT ACCESS TESTING
( Verify waiver explained, and paperwork correctly filled out )
Name:
Results Mailed By (Initials):
M
F
DOB______/_________/_________
Date:
Additional Comments:
Telephone #:
Check  Panels Below, or Individual Tests from RIght Column
R Indicates Reportable to Health Dept.
► Indicates 8-12 hour fast recommended.
R
►

Mnemonic
$
► Lipid Panel:
$20
► Basic Metabolic Panel:
PBM
Sodium, Potassium, Chloride, TCO2, Glucose,
Creatinine, BUN, Calcium
$25
Liver Panel: PLIV
Albumin, Total & Direct Bilirubin, AST, ALT,
Alkaline Phosphatase, Total Protein
$25
PLIP
Cholesterol, HDL, LDL Calculated,
Triglycerides
R
PCM
Sodium, Potassium, Chloride, TCO2, BUN,
Glucose, Creatinine, Calcium, Albumin, Bilirubin,
Alk. Phos., Total Protein, AST, ALT
$45
Renal (Kidney) Panel: PREN
Sodium, Potassium, Chloride, TCO2, BUN,
Glucose, Creatinine, Calcium, Albumin,
Phosphorus
$30
►
Bone Health Panel: VITD,CAL,PTHI,ALKPHOS,PHOS
Vitamin D, Calcium, Phosphorus, Parathyroid
Hormone, Alkaline Phosphatase
$80
►
► Comprehensive Metabolic:
► Heart Health Panel: PCM,PLIP,HSCRP,HOMOCY
R
$100
Comprehensive Metabolic Panel, Lipid Panel,
Homocysteine, C-Reactive Protein (High-Sens)
R
Complete Blood Count with Auto Diff: CBC
Includes White Cell Count with Differential, Red
Cell Count, Hemoglobin, Hematocrit, Platelet
count, Indices
$30
Urine Drug Screen:
UDS
Opiates, Benzodiazepines, Cocaine, Marijuana,
Amphetamines, Barbituates, Phencyclidine
$80
R
R
R
►
R
$110
R STD Panel: RPR,CHPCR,GCPCR,HIV
Chlamydia, Gonorrhea (PCR), Syphilis (RPR), HIV
Requires urine and blood sample
► Anemia Panel: CBC,FERR,VITB12,IRON,FOL
$100
Complete Blood Count, Ferritin, Vitamin B12,
Iron, Iron Binding Capacity and % Saturation,
Folic Acid
R Acute Hepatitis Panel:
HEPAP
Hep A Ab IgM, Hep B Core Ab IgM, Hep B
Surface Antigen, Hep C Antibody
$110
Thyroid Panel: TSH, FT4
Thyroid Stimulating Hormone, Free Thyroxine
$45
Celiac Panel: CELIAC
Tissue Transglutaminase Antibody IgA, IgA, Gliadin
Antibody IgA
$80
Iron Panel:
IRON
Total Iron, Iron-Binding-Capacity, % Saturation
$25
Immunization Panel: RUB,MUMPS,MEASIM,VARZIGG
Rubella, Measles, Mumps, Varicella Antibodies
$70
Blood Typing and Rh Factor
ABO Blood Type, Rh Factor
$15
TOTAL PAID:
DATYPE
CASHIER:
Indicates Reportable to Health Dept.
Indicates 8-12 hour fast recommended
R
►
Alkaline Phosphatase
ALT (Alanine Transaminase)
AST (Aspartate Transaminase)
Bilirubin, Direct
Bilirubin, Total
BUN (Urea Nitrogen)
Calcium
Carbon Monoxide
Chlamydia, PCR ( Urine )
Cholesterol
C-Reactive Protein, High-Sensitive
Creatinine
Estradiol
Ferritin
Folic Acid, Serum
Free T3 (Triiodothyronine)
Free T4 (Free Thyroxine)
GGTP
Glucose
Glycohemoglobin (HgbA1c)
Gonorrhea, PCR ( Urine )
Hemoglobin and Hematocrit
Hepatitis B Surface Antibody
Hepatitis B Surface Antigen
Hepatitis A Antibody, IgM
Hepatitis C Antibody
HIV
Homocysteine
Iron, Total only
LDL (Low Density Lipoprotein)
Lyme Titer
Magnesium, Serum
Measles Immune Status
Microalbumin, Random ( Urine )
Monospot
Mumps Immune Status
ALKPHOS
ALT
AST
DBIL
TBIL
BUN
CAL
CO
CHPCR
CHOL
HSCRP
CREA
ESTRA
FERR
FOL
FT3
FT4
GGT
GLUC
HGBA1C
GCPCR
HH
HBSAB
HBSAG
HEPAIGM
HEPC
HIV
HOMOCY
IRONT
LDLD
LYME
MG
MEASIM
UAMALBR
MONO
MUMPS
PHOS
Phosphorus
PLT
Platelet Count
K
Potassium
Pregnancy Test, Serum, Qualitative
PREGS
Pregnancy Test, Urine, Qualitative
PREGU
PSA (Prostate Specific Antigen Screen)
PSAS
RF
Rheumatoid Factor (RF)
RPR
RPR (Syphilis)
RUB
Rubella Immune Status
NA
Sodium
STREPADAT
Strep A Screen
Testosterone (Total, Free, Bioavailable)
TEST
TRANSF
Transferrin
TRIG
Triglycerides
TSH (Thyroid Stimulating Hormone)
TSH
URCA
Uric Acid
UADAT
Urinalysis
Varicella(Chicken Pox) Immune Status
VARZIGG
Vitamin B-12
VITB12
Vitamin D
VITD
DATE PAID:
You will be asked to address an envelope with your mailing address. Your results will be mailed to you upon completion.
The Direct Access testing Consent Form is on page 2. Laboratory staff will review it with you and ask for your signature prior to sample collection.
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$10
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$10
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$15
$35
$35
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$45
$30
$15
$35
$35
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$20
$20
$20
$20
$10
$10
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$35
$35
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$65
$30
$10
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$45
$40