TICK-BORNE DISESASE SEROLOGY
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TICK-BORNE DISESASE SEROLOGY PHONE County of Sonoma Department of Health Services Public Health Laboratory 3313 Chanate Road, Santa Rosa, CA 95404 Telephone (707) 565-4711 www.sonoma-county.org/laboratory Requested by: LAB OR CLINIC ADDRESS PHYSICIAN Lab Number Date Received Last First Address Medical Record # Collection Date Birthdate Sex Pregnancy Status ❐ Y ❐ N LYME DISEASE SCREEN ELISA WITH REFLEX TO CONFIRMATORY IgM AND IgG ELISAs ICD-10: _________________________ ANAPLASMA PHAGOCYTOPHILUM (HGA) IFA ICD-10: _________________________ EHRLICHIA CHAFFEENSIS (HME) IFA ICD-10: _________________________ BABESIA MICROTI IFA ICD-10: _________________________ BABESIA DUNCANI (WA1) IFA ICD-10: _________________________ RICKETTSIA TYPHI IFA ICD-10: _________________________ RICKETTSIA RICKETTSII (364D) IFA ICD-10: _________________________ (Rev 1/2021)
Transcript of TICK-BORNE DISESASE SEROLOGY
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County of Sonoma Department of Health Services Public Health Laboratory 3313 Chanate Road, Santa Rosa, CA 95404 Telephone (707) 565-4711 www.sonoma-county.org/laboratory
Requested by:
LAB OR CLINIC
ADDRESS
PHYSICIAN
Lab Number
Date Received
Last First
Address
Medical Record #
Collection Date
Birthdate Sex
Pregnancy Status ❐ Y ❐ N
LYME DISEASE SCREEN ELISA WITH REFLEX TO CONFIRMATORY IgM AND IgG ELISAs ICD-10: _________________________
ANAPLASMA PHAGOCYTOPHILUM (HGA) IFA ICD-10: _________________________
EHRLICHIA CHAFFEENSIS (HME) IFA ICD-10: _________________________
BABESIA MICROTI IFA ICD-10: _________________________
BABESIA DUNCANI (WA1) IFA ICD-10: _________________________
RICKETTSIA TYPHI IFA ICD-10: _________________________
RICKETTSIA RICKETTSII (364D) IFA ICD-10: _________________________
(Rev 1/2021)
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