Do Not Use
  This  Space

PRINT, APPLY LABEL OR STAMP:  DO NOT ABBREVIATE                        ONLY ONE TEST PER SUBMISSION FORM
1.	  Submitting Facility (Receives Test Result):     

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Facility / Laboratory Name  (required)

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Street Address

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City, State                                    Zip

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Phone #                                                Secure Fax #:	2.  Patient Info:

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Last Name,  First Name

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Street Address

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City, State                                                    Zip

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Patient ID:                                              Phone #:

4.  Sex:   M   F   Other         DOB:_________
	
	5.  Race:  (Check One)
•	American Indian or Alaska Native	  Asian
•	Black or African American	  White
•	Native Hawaiian or Pacific Islander	  Other	
3.	Ordering Clinician/ Phone# (required):

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Clinician Name (First and Last Name)                                            Phone number#
		
	6.  Ethnicity:    Hispanic or Latino    Non-Hispanic or Latino	

Test Requested:  				Collection Date:  			Date of Onset:
____________________________		____________________		______________________
(required)   One Per Form	                          (required)   One Per Form 		(required)

Serology		Culture	
	Acute		Contact		Test of Cure		Date of Culture: 	
	Confirmation		Surveillance				Date of Subculture:	
	Convalescent		Symptomatic				Sample Treated    Y   N      If yes, how:  	

Source of Specimen:  (required)   One Per Form
	Anal canal		Nasopharynx		Stool		Body Fluid (site)	
	Blood		Plasma		Throat  (pharynx)		Bronchus (site)	
	Bone Marrow		Serum		Urethra		Exudates (site)	
	Cervix		Spinal Fluid		Urine		Wound (site)	
	Gastric		Sputum				Tissue (site)	
	Other:  (Specify)	

Additional Patient Information:
Symptoms, and Duration
	
Travel History (Dates and Locations)
	
Animal / Insect contact: (specify)
	
Relevant Immunizations (Dates)
	
Previous Laboratory Results

Please fill out “Additional Patient Information” section on front of form for the following tests:

Adenovirus
				Herpes	Rickettsia	
Arbovirus testing
	Influenza	Respiratory Synctial virus  (RSV)	
Babesia

	Lymphocytic choriomeningitis virus        (LCM)	Rubella	
Campylobacter
	Legionella	Salmonella	
Chikungunya
	Lyme Disease	Shigella	
Cytomegalovirus    (CMV)
	Measles	St. Louis Encephalitis	
Dengue Fever
	Mumps	Syphilis	
E. coli
	Mycoplasma pneumoniae	Vaccinia virus	
Eastern Equine Encephalitis
	Parainfluenza	Varicella zoster	
Enterovirus
	Parasitology serology	Vibrio	
Ehrlichia
	Pertussis	West Nile Virus	
Hantavirus
	Q Fever	Yellow Fever