EFTA00298596.pdf

General Test Requisitioi ( Quest Atiesdeinecemincoporse OreltricolP‘renty Nacre IITCHLLL KLIHE, 10101,25 • Dii4JIICS:‹ Teteturo,ELIEACe 703 PARK AVE AdrPess hwappoismitAiM MEirlitEritaC04Wappairt-mal Rtli ?UR RI 10321 te callIPS2Ti4772 Telephone 212-517-6555 A4110wI1Numbe T92816- 8 1062 RE- CsOER 1722002 Patient1Hk - rust Ham) I I , t1 I I..... • I• - I S ; CrestiPISMO .. i l ' A A Ono Collected Um Wetted O Am samara O !tie AP- 1-1 t'l 6 , .1 I •' C] PM Non fasting 0 VMume Timed UM. Cacti; /mime/ Inwood s Andrea APE, Accession Numbs of mechm Rows TtlY 'Stye 'Op Remote me Prim on Report: 'Mal e 'Gated Birth Monet, Day.Yead e - iiiiiii% C] insinenCe Please Bill To: J3 Paint ea. : O UNCertIlSelect --- EJ 'Frei Mt. Telephone WON 0 1 5 Inly-1 si. Pawl/ Mart L0 I I I I 1 f Manii Nawfill OfferoMfflunPMkM4 Palen Rcilmondue to lowed 0 See O Spouse O OePeodem ( ) I I I ! J IM Poky limmeer Meals P asE or Suffixl Croups IOnNainellysician WOrmabila Ia. ' 114,,;i O4 --3.7- 414002Th -4 1-1- 144807 1432136231 KURE MITCHELL 1 ) 212374 1.20S9S2S15 .maninittsx -....h.:_ ridiwyknume, Name end r; cep Nano BROWN Kam ( ) 1497049548 "Mrinlift" ( ) ( ) Oakes Submission MMus ( ) `Rem Memoriam Indlim or Najtimftkriu_I;;IMILLI$Ipilic ri week Cl White 'D 19,011195id _0 0709L---Sa ‘Un9"--- ", DUPIJICATE L Physican's Name and Address of Clued OtaignOMIce Am 0 I oNsicieWs Somme CIFAX ( ) REPORT TO r , 1 7, s .. ICD Diagnosis Codex ' II ►0. L -1 ( ) (Enter All That Apply)6. - .. ." 1 I644'T NSV 1/ 2 1AS HERPESUCCT L 173028 THYROID A (W/8,7PM 1 /10643X SESP ALLERGY PROF REG I 14725 Cd/HC8/C8 t 157S1E CULTURE,FURWSREAR,H,S,R 1P4418 C4/C3/CBM .CHEHT CH50 t 11;271 LYME DISCASE,CIR HMI 118 1 7104928 AKA/SR.' IriESIUT-ARGAFURIC 0CIetnrontr RET/Sh, E 117669X RHEMATOI0 ARTHRITIS HAG Plum0304480ProfilefelfTemleiles se slueselimhe hes ussamses TheserseemesmeetsMIPROMECOMPONUITIMY WORMED SIMMIELY MICROBIOLOGY / VIROLOGY Reim bison pertained et an adeitiosal dame. 141A • CIEC-PettleXPAIICReCli L 26013E O Magnesium S 9301A C]CUw mlMeued SwotW 0 PANIEL/PROFILE OFFERINGS 92A ea RAIfit RISCMCPL Om L 660x LDMiceamiberim RaW A miler) U Moltensite ersourarno S. 715F OFNerolyte Pent/ BX 20396R Ca SR 396658 0 Pfiennoin (Nitwit(' SR Ma C)Bwees Oita HS4Pimid s 20750E O Worlds ale! O Horses Culture. 115V.RIRI WTY0419 12296E OHepatic Function Pane/ S 27171E O PhomINNus S 3251A CI 1.1,ct4ceila 022aSoutin inn, DUE Motabolic Panel Wean BX 20533E • CholesterolJotel S 2622E O Potassium S Sas AM last Seam I 1$731A M Comp. Nlenbolic Pend einCRI BX 19885R O G-Reedite Protein S 2814E 0 RENEsIA Total $ 1740( [306 F +Riede Ag. SrA ' . • gin Dupes Penh s 21600E 0 Creatinine edeGFR S 28671E O PSA, Tote! $ nen 1:10 sRsts • 148515( OlipiJ Panel wiRenex DUX s 356348 0 Cligoxin SR 26F OPT (Prothromnin Ter 9) B MIX O CUM; 2102144:0600444trulochboal • 10706E EINeadts Flaw. viRtAcute SR 51577E El rev. CAPS1D AB, IgG S 71711E O aPTI B 112111010 Sem Grow AllemPIM i • •IIT OCHEMECREEN* Panel (Basic Pill) ex 51599w0 ESV• SAPS'S Aft IgM S 11577580 Rheumatoid Factor S ...,. Amplified Swims. T • (please Mack ens) 551E OCHE/A.80CW Panel 8 HOE BX 45377W C3 ESA, Westergren (See beck -) L 1156E O APR wrnellex to Tilt .410 F1A-Ab S El Endocereical LI Urethral ClUrine nn* OCHEMSCREEN. Pang 5 HOUTIESC BX 27764R O Fer6tin 43476F OCHELI-SCREEN• ex 72848W LI FiNale SR 11483 O RPR *Males toIt • S B$IX OChlonelneRNIATMs SR 29512E O Sodium S It CIL gonceitneeelGOFWA TMA stigunamitip Kr Igoe Ban 2:2347W O Buctoomino S 706368 O 73, Total SR 11SZI OEMs:nen &IX goonefieme WAWA 7SIA ? l ath Profile 1 BX, i 7842E 0 GGT S 30582E 013. Uptake S INDICATE ADDEII ONAL TESTS HERE •am III AMritis Profile III s. L 67777W O 6leCose GY 3024N/024, Roe S 6531 Olivet Panel II s 265E 0 H8sAgrotoirlimation S 304918 O Triglycarides S 5133A °Lymph Subsets Profile III L, GN WI" 0 KG' 'Mimi al SR 43562A O ISH *Reflex to Fre• T4 S mutt' OTherold Profile, Resit s 11113E C3 NCO, Total, ON SR 3019E O TSH $ 24867W O MX. Cholesterol S MF O UA Complete (Mum 6 Mt, V OMEN TESTS 45443E O Hem/toe:ft 1 WA O LIA, Microscopic U 17517W O Albumin S 7181W C3 Hemoglobin L 86702A IDUA. IN/Reflex to Mi:roscopie U 67686R O Alkaline Phosphates, $ 45484R O Hemoglobin AIC 17NNR C3 ALT ISGPD L 309401 OUMe Nitirogim (BUN, S S 51813E 0 Hepatitis A thus AB IgM $ ASK Olkic Acid S mmO Amylase, Serum S 5IBAR 249X O ANA IFA SCRveltell Tiler O Hepatitis 8 Coe A8 NM S 51031E [3Varicella Zoger k6 S s 1062 1062 6041 O ApalipoprotoinMai 8 S 6477X o Hemais c vivo AB S 21709Wfl Vitamin 8•12 SR T72816-8 T92814-8 istfalW O AST (SCOT) S 2,281E O Hcomeysteine (Cannot 4* - MICS081020BVVItOISSY 19187W O Unita Deed 74984R O Iron S 19152E O Bahrein, Total S 0 Iron and TILIC S SOURCE: 11762 1062 113341E O CA125 s 751104 O LD (Lamm@ Deldromnasal S #Addmoni charge wisficgpssain 192016-0 T92814-0 29773E O CA27.29 sR 20909W O LDL Cholesterol, Direct S onsR Da iwa 601.4"c 0..4 20101IN O Calcium s 30463E O lipase S SIMV O Wan GenitatCrois , Sep. e 1062 1062 zaraw O Carbon Dioxkle s 9076E O Lyme Nom AtigGaigMW0 S moiR O Cullum Urfreitetire . 4. 192816-8 T92816-8 101241 O Cards° CRP $ iSMY C3 Lwm Oman SonmeditimoNS S 62842WEI BeLie,Bad Conn yis'ete - - . ... -- -r ........ism.Marton......It 0Oa Otiomitlasnensa Ai man am se Pm 2! IIIMMIlett EFTA00298596