OTHER

Glucose (82947)

Client ID:

Myeloperoxidase (83876)Lp-PLA, Activity (83698)High-Sensitivity CRP (hs-CRP) (86141)Microalbumin/Creatinine (82043/82570)ADMA/SDMA (82542)Oxidized LDL (83516)F,-Isoprostance/Creatinine (82542/82570)

INFLAMMATION

Standard Lipid Panel(Includes non-HDL cholesterol) (80061)

If TGs > 400 mg/dL, reflex to a Direct DL (83721)ApoB (82172)ApoA1 (82172)sdLDL (83701)Lp(a) (83695)HDL2b (82664)NMR LipoProfile® with Lipids (83704/80061)*

ADVANCED LIPIDS

Insulin (83525)Reflex to Adiponectin if indicated (83516)

OGTT (82951)GLYCOMARK® (84378)HbA1c (83036)

DIABETES

Galectin-3 (82777)NT-proBNP (83880)*

HYPERTENSION/HEART FAILURE

Reflex to GLYCOMARK® if indicated (84378)Adiponectin (83516)Fructosamine (82985)C-Peptide (84681)Cystatin C (82610)Homocysteine (83090)

Coenzyme Q10 (82542)*Vitamin D, 25 OH (82306)Vitamin D2/D3 (82306)Folate (82746)RBC Folate (82747)Vitamin B12 (82607)

VITAMINS/SUPPLEMENTS

Testosterone, Total (84403)Estradiol (82670)FSH (83001)Luteinizing Hormone (83002)Progesterone (84144)

T4, Free (84439)TE. Total (84436)T3, Free (84481)T3, Total (84480)

THRYROID FUNCTION

Practice Name:

Practitioner ID:

Practitioner Name:

NPI:

Address:

City:

Phone:

PRACTITIONER INFORMATION

State:

Fax:

Zip:

Tim

e:In

itia

ls:

Dra

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ate:

PSA, Total (84153)Reflec to PSA, Free if indictated (84154)

Reflec to PSA, Free if indictated (84154)

CANCER

PSA, Total (G0103; Medicare)

AspirinWorks® (84431/82570)COAGULATION/PLATELET FUNCTION

Fibrinogen Mass (85385)

CYP2C19 (81225)GENETICS

ApoE (81401)MTHFR (81291)Factor II (81240)Factor V (81241)

Ferritin (82728)ANEMIA/IRON METABOLISM

Iron (83540)Serum Iron & IBC (83540/83550)

TSH (84443)Reflex to T4, Free if indicated (84439)Reflex to T3, Free if indicated (84481)

Basic Metabolic Panel (80048)ROUTINE PANELS

Comprehensive Metabolic Panel (80053)Hepatic Function Panel (80076)Renal Function Panel (80069)Electrolyte Panel (80051)

CBC/Auto Diff (85025)*STANDARD LABORATORY TESTS

CBC (85027)Urinalysis (81001)*Uric Acid (84550)Creatine Kinase (82550)

TB Gold-Quantiferon (86480)INFECTIOUS DISEASE

__________________________ _______________________________________ _____________

Influenza A & B (87502)MOLECULAR TESTING

Strep A/CG (87651, 87798)HSV/Vericella Zoster (suab) (87529x2, 87798)

__________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _____________* Sample must be shipped the same day collected.** Sample must be protected from light.

Date: XPractitioner’s Signature: X

16750 Red Oak DriveHouston, Texas 77090Phone: 281-453-7855

Fax: 281-453-7636

TEST MENU (Please fill in box completely)

LABORATORY REQUISITION

Trichomonas (urine) (87661)

PT/PTT (86510, 85730)D-Dimer (85379)

SJ ASSOCIATED PATHOLOGISTS, LC

PATIENT INFORMATION

Address:

City:

Phone:

Other Patient ID:

Race:

State:

Fax:

Zip:

First Name:

Ht:

Last Name:

DOB:

Address:

Last 4 SSN Digits:

Middle Initial:

BMI: FastingWt:

American Indian/Alaskan Native

White/Caucasian (Non-Hispanic)

Asian

Hispanic/Latino

African-American

Other

Yes No

Male Female

Patient Demographics Sheet Attached

PROVIDENCE PANELS

Female Wellness Panel <40Female Wellness Panel +40

Hepatitis PanelSTD Panel

Male Wellness Panel <50Male Wellness Panel +50

RESPFOODS

ALLERGY PANEL

Thyroid PanelAntiphospholipid PanelConnective Tissue

* Please see back of Requisition Form for Panel Details

AUTOIMMUNE PANELRA PanelCeliac Disease PanelLiver Disease Panel

DX CODES:

Z00.00 General medical examI51.9 Cardiovascular DiseaseE78.9 Disorder of Metabolism E07.9 Disorder of Thyroid

E34.9 Hormone/Endocrine disorderE23.0 HypopituitarismD48.9 ImmunodeficiencyD50.9 Iron DeficiencyZ79.891 Long term use of opioid analgesicE63.9 Nutritional deficiencyE66.9 Obesity, UnspecifiedE23.6 Other disorders of pituitary glandR53.83 Other fatigueZ79.899 Other long-term drug therapyR53.81 Other MalaiseZ12.5 Screen for prostate neoplasmE55.9 Vitamin D deficiencyE56.9 Vitamin deficiency R53.1 WeaknessM12.9 ArthropathyG89.4 Chronic Pain Syndrome

Z13.21 Encounter for screening for nutritional disorderZ13.228 Encounter for screening for other metabolic disorder Z13.29 Encounter for screening for other endocrine disorders

COMMENTS

G89.28 Other Chronic postoperative pain

R68.82 Decreased LibidoE11.9 Diabetes II, UncomplicatedN42.9 Disorder of Prostate

E03.9 HyperthyroidismN59.9 Menopausal DisorderM19.90 OsteoarthritisM19.049 Osteoarthritis, handM79.609 Pain in LimbM25.569 Pain, KneeG93.3 Postviral fatigue syndromeN41.9 ProstatitisR97.2 PSA, elevatedM06.9 Rheumatoid arthritisM75.100 Rotator cuff shoulder syndromeM46.1 SacroiliitisM54.30 SciaticaR06.02 SOB

N92.0 Excessive/Frequent menstruationM79.7 FibromyalgiaR52 Generalized PainR51 HeadacheE79.0 HypercholesterolemiaI10 Hypertension

D84.9 Immune deficiency disorderR76.11 Positive PPD

Z79.899 Medication Management

Z77.21 Exposure to Potentially Hazardous Body Fluids

Testosterone, Free (84402)HORMONES