LAB ID 2ALNI/04610 |
THE SKIN CENTER LAB ORDER |
(REVISED 11/1/11) |
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SEND EXTRA COPY TO DR : |
THE SKIN CENTER |
LAB WEST/ LABCORP MEDICAL LABORATORIES |
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Alai, Nili N. M.D. |
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26081 Merit Circle #109 |
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□ STANDING ORDER |
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Laguna Hills, CA 92653 |
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Expires 6months from date |
Telephone 949-582-7699/ FAX 949- 582-7691 |
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QUEST ID: 92653106-9 |
**TESTS ARE NON-FASTING & ROUTINE UNLESS MARKED OTHERWISE |
□ FASTING |
1. ALOPECIA 704.1 |
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2. ACNE / HIRSUITISM |
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3. AUTOIMMUNE/ LUPUS |
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4.PRURITIS |
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A. Malaise/ Fatigue 780.79 |
A.Hypertrichosis 704.1 |
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A. Dermatitis 692.9 |
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A. Pruritis 698.9 |
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B. Dermatitis 692.9 |
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B. Malaise 780.79 |
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B. Malaise/ Fatigue 780.79 |
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B. Malaise/ Fatigue 780.79 |
CMP(COMP METABOLIC) |
80053 |
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C. Acne 706.1 |
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C. Pain |
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C. Dermatitis 692.9 |
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CBC, DIFF, & |
PLTS |
82025 L |
CMP |
82150 |
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SED RATE |
85651 |
2L |
CBC, DIIF, & |
PLTS 85025 |
L |
URINALYSIS |
81003(1) |
UR |
CMP |
80053 |
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RPR- ROUTINE |
86592 |
S |
SED RATE |
85651 |
2L |
ANA (EIA) |
86039 |
S |
CBC, DIFF, & |
PLTS |
85025 L |
ANA (EIA) |
86039 |
S |
Free testosterone |
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DS-DNA |
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SED RATE |
85651 |
2L |
FERRITIN |
82728 |
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Sex hormone binding globulin |
RNP-SM |
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ANA (EIA) |
86039 |
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FOLATE |
82746 |
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DHEA-S |
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ANTI-RO (SSA) |
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FERRITIN |
82728 |
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IRON |
83540 |
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Androstenedione |
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ANTI-LA (SSB) |
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FOLATE |
82746 |
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T4 |
84436 |
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3-Androstanediol Glucoronide |
SCL-70 |
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IRON |
83540 |
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TSH |
84443 |
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TSH |
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HISTONE |
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TSH (3RD GEN) |
84443 |
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VIT B12 |
82607 |
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Free T4 |
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C3, C4, TOTAL COMPLEM |
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VIT B12 |
82607 |
S |
■ Free testosterone |
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□ Level Two (FASTING) |
TPO ANTIBODY |
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H. PYLORI AB IgG & IgM |
■ Thyroglobulin Auto Abs |
Prolactin |
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RHEUMATOID FACTOR (RF) |
IgE |
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■ Thyroid peroxidase (TPO) |
FSH, LH |
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ANTI CARDIOLIPIN ABS |
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ANTITHYROID AB |
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■ DHEA-S |
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Fasting glucose |
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ANTI-SMITH ABS |
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HEP B, C SCREEN |
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■25- Hydroxy Vitamin D |
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Fasting insulin |
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ANTI-MITOCHOND ANTIBODY |
TPO |
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*If ANA+, please run full Lupus Panel |
17 alpha-OH progesterone |
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*If ANA+, please run full Lupus Panel |
including C3, C4, RF DS-DNA |
Lipid profile |
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including C3, C4, RF DS-DNA |
anti-SM, anti-RO, anti-LA, etc |
25- Hydroxy Vitamin D |
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anti-SM, anti-RO, anti-LA, etc |
5. URTICARIA 708.9,Dermatitis 692.9 |
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, Malaise/ Fatigue (780.79) |
6. VITILIGO 692.9, 780.79 malaise |
7. ONYCHOMYCHOSIS 101.1 |
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DX Pain 780.96 |
H.Pylori AB |
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Hep A, B, C screen |
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Anti-TPO antibody |
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CMP |
80053 |
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CMP |
80053 |
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TPO ANTIBODY |
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Thyroid peroxidase Antibody |
CBC, DIFF, & |
PLTS 85025 |
25L |
CBC, DIFF, & |
PLTS 85025 |
L |
thyroglobulin auto abs |
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CMP |
80053 |
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STANDING ORDER REPEAT |
SED RATE |
85651 |
2L |
STOOL O&P & C&S |
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CBC, DIFF, & |
PLTS 85025 |
L |
MONTHLY X 4 MOS |
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ANA (EIA) |
86039 |
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SED RATE |
85651 |
2L |
EXPIRES DATE: in 6 Months |
T4 |
84436 |
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**If ANA+, please run full Lupus Panel |
ANA (EIA) |
86039 |
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(6 mos from today’s date) |
TSH |
84443 |
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including C3, C4, RF DS-DNA |
FERRITIN |
82728 |
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And repeat every 4 wks |
IgM + IgG + IgE |
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anti-SM, anti-RO, anti-LA, etc |
FOLATE |
82746 |
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while on Lamisil/Sporonox |
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IRON |
83540 |
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8. GENERAL CHECKUP |
TAKE TO ANY LAB: LOOK UP LOCATIONS ON LINE |
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T4 |
84436 |
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CMP |
80053 |
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1. LAB CORP 949-586-6590 |
www.labcorp.com |
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TSH (3RD GEN) |
84443 |
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CBC, DIFF, & |
PLTS |
85025 L |
2. QUEST DIAGNOSTICS (949) 380-9980 www.questdiagnostics.com |
VIT B12 |
82607 |
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Fasting Lipid profile ( Cholest, Triglyc) |
PLEASE ASK LAB TO FAX RESULTS TO THE SKIN CENTER |
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25- Hydroxy Vitamin D |
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9. Propecia every 6-12 months |
RADIOLOGY ORDER: ORANGE COAST IMAGING CALL 949-462-3999 FAX 949-462-3777 |
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CBC, DIFF, & PLTS; COMP METABOLIC |
1. XRAY of Chest – 2 views PA and Lat DX cough |
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PSA |
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2. CT SCAN CHEST ABD PELVIS with and without contrast DX: PAIN, NEOPLASM |
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3. Ultrasound Pelvic- DX cystic ovaries, PCOS |
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10. ROUTINE AEROBIC CULTURE |
4. MRI C- Spine |
Dx: Neck pain, Disc disease |
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CULTURE & SENSITIVITY ( C&S) |
5. Ultrasound Legs- Veins, dx clot |
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SEE TUBE FOR COLLECTION TIME |
6. Mammography: Screening unless marked otheriwse □ Diagnostic- lump breast |
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SOURCE: SKIN ** see tube |
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PATIENT’S NAME: |
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MD SIGNATURE: |
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DX: 692.9 dermatitis |
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REQUIRES SIGNATURE***** |
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DX: 695.9folliculitis |
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DATE OF BIRTH: |
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DX: 704.8 |
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