Place Label Here Advanta Analytical Laboratories Phone: 903.805.9955 10935 CR 159, Tyler, TX 75703 Fax: 903.839.2494 Lab Director: Dr. Owatha Tatum, Ph.D. CLIA#: 45D2063134 www.aalabs.com CLIA#: 45D2072790
Laboratory Drug Testing Requisition SAMPLE TYPE ORAL FLUID URINE
PATIENT INFORMATION Ordering Provider Gender Date
Patient Name DOB DOI (Work Comp Only)
DIAGNOSIS CODES – Please specify chief complaint, any additional complaints, and their diagnosis codes Complaint 1 Complaint 2 Complaint 3 Complaint 4 Diagnosis Code Diagnosis Code Diagnosis Code Diagnosis Code
LCMS TESTING MENU p61 – Identify with a check mark box ( ✓ ) all drug classes or individual drugs to be tested. Opiates & Opioids (22) Antidepressants (8) Stimulants (6) Anti-epileptics (2) Codeine Amitriptyline Amphetamine Gabapentin Dihydrocodeine Desipramine MDMA Pregabalin Hydrocodone Doxepin MDPV Sedative Hypnotics (3) Hydromorphone Fluoxetine Methamphetamine * Zaleplon Morphine Imipramine Methylphenidate Zopiclone Naloxone Nortriptyline Ritalinic Acid Zolpidem Naltrexone Paroxetine Illicits (5) Alcohol (2) Norhydrocodone Venlafaxine 6-MAM Ethyl Glucuronide Noroxycodone Benzodiazepines/Sedatives (9) Benzoylecgonine Ethyl Sulfate Noroxymorphone 7-Aminoclonazepam Ketamine Barbiturates (6) Oxycodone Alpha-OH-Alprazolam Norketamine Amobarbital Oxymorphone Alprazolam Phencyclidine Butabarbital Buprenorphine Chlordiazepoxide Illicits + Alkaloids & Cannabinoids (8) Butalbital EDDP Desalkylflurazepam 6-MAM Pentobarbital Fentanyl Lorazepam Benzoylecgonine Phenobarbital Meperidine Nordiazepam Ketamine Secobarbital Methadone Oxazepam Norketamine * D&L Methamphetamine Norbuprenorphine Temazepam Phencyclidine performed for any positive Norfentanyl Muscle Relaxants (3) Cotinine methamphetamine O-Desmethyl-Cis-Tramadol Carisoprodol Nicotine Tapentadol Cyclobenzaprine THC Tramadol Meprobamate
URINARY TRACT PANEL/STD ANTIBIOTIC RESISTANCE GENES Enterococcus faecalis Staphylococcus aureus Streptococcus pyogenes (group A) Aminoglycoside (ant-la, aph3) Enterococcus faecium Candida albicans Trichophyton species Beta Lactamase (TEM and SHV) Klebsiella pneumoniae Candida parapsilosis Chlamydia trachomatis Carbapenem (KPC, NDM, OXA48) Escherichia coli Candida glabrata Neisseria gonorrhocae Fluoroquinolone (qnr, gyrA) Pseudomonas aeruginosa Candida tropicalis Tetracycline (tetB and tetM) Proteus mirabilis Streptococcus agalactiae (group B)
PROVIDER’S ORDERS SAMPLE INFORMATION
Perform qualitative analysis only. TIME AM / PM Temperature checked within 4 minutes of collection Perform quantitative analysis only. DATE and between 90-100° F or 32-38° C? Perform qualitative and quantitative analysis. COLLECTOR Yes No
MEDICATION LIST ATTACHED, or list prescribed medications below.
PROVIDER’S SIGNATURE PATIENT CONSENT
Provider’s testing orders are identified with a check marked box ( ✓ ) above for testing by I verify that I am providing Advanta Analytical Laboratories and affiliated reference Advanta Analytical Laboratories and/or its affiliated reference laboratories (CLIA#: 45D2063134, laboratories (CLIA#: 45D2063134, CLIA#: 23D0650582) with a sample of my CLIA#: 23D0650582). By my signature, I certify the testing is medically necessary. urine, blood or oral fluid for the purpose of testing. Provider’s Signature Date Patient Signature Date
AAL p61 - V1.2