Comprehensive Gastrointestinal Requisition

Patient Information

Patient Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Phone Number

Sex *

SS Number

Physician Iinformation

Requesting Physician Signature *

Collection Information

Date Collected *

Time *

Collection Site *

Billing Information (please attach copies of all cards, front and back)

Primary *

Insuance Carrier:

Policy / ID Number

Group Number

Secondary *

ICD-10 Codes(s)

(See List Below)

Specimen Submitted

Panel

Gastrointestinal Pathogen Panel (Swab)

Bacteria
• Campylobacter (jejuni, coli, and upsaliensis) • Clostridium difficile (toxin A/Bl • Plesiomonas shigelloides • Salmonella • Yersinia enterocolitica • Vibrio (parahaemolyticus, vulnificus, and cholerae) • Vibrio cholerae Diarrheagenic E. coli/Shigella • Enteroaggregative E. coli (EAEC) • Enteropathogenic E. coli (EPEC) • Entertoxigenic E. coli (ETEC) It/st • Shiga-like toxin·[Jroducing E. coli (STEC) six l / stx2 • E.coli0157 • Shigella/Enteroinvasive E. coli (EIEC)

Parasites
• Cryptosporidium • Cyclospora cayetanensis • Entamoeba histolytica • Giardia lamblia

Viruses
• Adenovirus F40 / 41 • Astrovi rus • Norovirus GI/GIi • Rotavirus A • Sapovirus (I, II, IV and V)

Stool Diagnostic Tests *

REQUIRED: Approximately 10 scoops of fresh stool must be submitted in a sterile container.

SPECIMEN REQUISITION & LABEL INSTRUCTIONS:

1. Fully complete requisition form witli all required information.
2. Complete specimen label with patients date of birth and full name.
3. Remove label and place bar coded label VERTICALLY on the specimen vial (not on the lid).

* Please ensure the patients date of birth and full name is indicated so that both the label and requisition match. Two patient identifiers are required on each specimen submitted. The unique barcode identifies the patient with this requisition form.

Patient Consent: I authorize payment to be paid to A2Z Diagnostics, LLC shown above for laboratory testing benefits otherwise payable to me. I understand I am financially responsible to A2Z Diagnostics, LLC for charges not paid or payable under my insurance program attached. I understand that my insurance may not be able to honor this request. If they cannot, they will pay the benefits directly to me as the insured and will direct payment to A2Z Diagnostics, LLC.

Patient Signature *