Requisition for Metabolic Screening Lab

Fill out the form below and print out to mail with your sample

Patient

Name:
Address:
I.D.#:
Birthdate:

Requisition for
Metabolic Screening Lab, St. Louis University,
Biological Fluid Organic and Amino Acids and Carbohydrates
by Gas Chromatography / Mass Spectrometry
CLIA Registration Number: 26DO652021

Reference
J. Chromatography Biomed. Appl. 1991 562:125-138

Diagnosis / Reason for ordering this test:
Patient known to be infectious?

Etiologic Agent:

Sample Source:

Urine:  

24 hour:

Timed:

Duration:

Casual:
 
Amniotic Fluid  

Weeks Gestation:
 
Date of Collection:
 
Diet over time of collection  

Regular:

Restricted:

Fasting:

IV's:

Formula/ Diet:
 
TPN:
Medications:

Person to whom report should be sent

Name:
Institution:
Address:

Preference for report delivery

Regular Mail  

Address:
Express Mail/Courier:
Phone Number:
Fax Number:
Modem Number:

Login Info

Person to Whom Invoice should be sent:
(If patient, please include full agency or insurer information)
Signature of Ordering Physician:  
(This signifies the patient has been informed of the nature of the genetic aspects of this test, if any, its constraints, the steps involved and its accuracy)

Send 1-5 ml of sample on dry ice, with this form, by overnight courier to:

James D. Shoemaker MD PhD
Director
Metabolic Screening Laboratory
3555 Vista Avenue (Rear Door)
St. Louis, MO 63104
314.977.9230