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REFERRING CLIENT/COLLECTION CENTER
VANDERBJLT PATIIOLOGY LABoRATORY SERVICES
Nashville:
(615) 936-0510
•
Continental U.S. :
(VPLS) VPLS CLIENT ACCOUNT
(800)551-5227
BILL TO:
SEND SPECIMEN (S) TO:
Client Account
4607 The Vanderbilt Clinic
1301 Medical Center Drive
Nashville TN 37232-5310
PATIENT NAME (LAST)
(FIRST)
SEX
DATE OF BIRTH
I
DATE COLLECTED
TIME COLLECTED
1- I
SERUM 0
I -I
I
1-1
PLASMA 0
URINE 0
I -I
PHONE NUMBER
(M.I.)
FOR LAB USE ONLY
3G MR#
PATIENT ID NUMBER
DFEMALE DMALE
I
Patient (Billing information must be attached.)
REFERRING PHYSICIAN
3G
' - - - - - - - - - - ' (CLIENT)
REQUEST#
SAMPLE ID
B ~l
L.,.__ _ _ _ _ ___J
OTHER
3G
(REFERENCE)
URINE TOTAL VOLUME
TOXICOLOGY TESTING
REFERRING LOCATION: _ _ _ _ _ _ _ _ _ _ _ _ PHONE: _ __ _ _ _ __ _ __
DSA
DRUG SCREEN URINE
Salicylates
Acetaminophen
Ethanol
Methanol
Isopropanol
Acetone
Phenothiazines*
Ethchlorvynol*
Amphetamines*
Barbiturates*
Cannabinoids*
Benzodiazepines*
Methadone*
Cocaine Metab.*
Opiates*
Tricyclics*
VSS
VOLATILE SCREEN BLOOD
DSV
VOLATILE SCREEN URINE
Methanol
Ethanol
Isopropanol
Acetone
DSS
DRUG SCREEN SERUM
Salicylates
Acetaminophen
Ethanol
Methanol
Isopropanol
Acetone
Acid Extraction Confirmations
CTF
GCB
ETHCHLORVYNOL
BARBITURATES
Base Extraction Confirmations
GCF
GCA
GCM
GCC
GCT
PHENOTHIAZINE$
AMPHETAMINE CLASS
METHADONE
PHENCYCLIDINE
TRICYCLICS
Other confirmations
GCZ
THC
BEG
GCO
BENZOD IAZEPINES
CANNABINOIDS
COCAINE METABOLITE
OPIATES(includes oxycodone)
Blood Drug Tests
ACE
ETH
EG
ISP
MTH
SAL
ACETAMINOPHEN
ETHANOL
ETHYLENE GLYCOL
ISOPROPANOL
METHANOL
SALICYLATE$
*all positive tests will reflex to confirmation
testing, additional charges may apply
For more information or assistance, please call :
VPLS 1-800-551-5227
VMC TOX LAB (615)322-0162
MDC
MISC DRUG CONFIRMATION
[please list drug (s) requested)