Molecular Epidemiology Lab Test Request Form

The John Hopkins Hospital Molecular Epidemiology Labs Test Request Form
Hospital Name: Account #:
Contact: Request Date:
Phone: FAX e-mail:
	Mailing Address (for results):		Mailing Address (if different):




Attention:		Attention:
List of Isolates for Strain Typing Genus and Species:
Test Code: 7103 Lab: 40 Revenue Center: 467

The minimum information requested is specimen number and collection date. To maintain patient confidentiality, patient names may be coded or omitted. Gray area is for JHH lab use.
	Patient Name/Code	Specimen Number	Collection Date	Body Source	Comment	Broth	Extr.	Gel	Fro- zen
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Epidemiologic Question
	Date Received:
Please print this form when finished.
JHH Molecular Biology: Lab Phone: (410) 955-2642 Lab FAX: (410) 614-8087