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Today’s Date__________ Patient ID__________ Name: _______________________________ DOB: _____________ Labs: _____ Today _____ Return _____ Stat Lab draw Date: ____________________ Return appointment with Physician____________________________________________ Lab: ARMC outpt LabCorp Mullins Quest Southside Other: ____________________ Hospital: ARMC Barnwell Edgefield Barnwell Med. Center Imaging Center ****PLEASE FAX ALL RESULTS TO: (803) 641-9143**** Frequent Labs: ____ CBC ____ CBC with Diff ____ Renal Panel ____ Basic Metabolic ____ CMP ____ Mg ____ Phos ____ Uric Acid ____ Hepatic Panel ____ Intact PTH ____ 25-OH Vit D ____ Ionized Calcium ____ 1,25 OH Vit D ____ Fasting Lipid w/ LDL ____ Chol ____ Trigs ____ HgbA1c ____ HgbA1C (In Office) ____ CMP,cbc/diff, Fe, Phos, uric acid & Transferrin Urine Studies: ____ UA ____ UA C& S _____UA(In Office) ____ Spot urine protein and creatinine ____ 24 hr. urine protein and creatinine ____ Other _____________________________ Anemia: ____ Iron ____ Transferrin ____ Ferritin ____ %Sat ____ FOB _____B12 _____RBC Folate ____ Retic. Count Routine Transplant Labs: ____ CBC, CMP, Magnesium, phosphorus, Uric acid, Lipid with LDL and UA, spot urine protein and urine creatinine Immunosuppression: ____ Cyclosporin ____ Tacrolimus/FK-506/Prograf ____ Sirolimus/Rapamycin ____ Free Mycophenolate level (MPA) Consults: ALL Consultations use HIPPA forms Cardiac/US Renal Doppler: Must use: CAROLINA HEART & VASCULAR FORMS Miscellaneous: ____ PT/PTT/INR ____ sTSH ____ T3 Uptake ____ Free T4 ____ PSA ____ Testosterone ____ Amylase ____ Lipase ____ Renin ____ Aldosterone ____ Other ____________________________________ ____________________________________ ____ HIV ____ SPEP ____ RPR ____ Hepatitis, Acute (HAAb, HBsAg, HBcAb, HBsAb, Cab) ____ Urine protein electrophoresis ____ Hepatitis B sAg only (HBsAg) ____ ANA ____ Anti DS DNA ____ Anti Smith ____ Complement C3 ____ Complement C4 Renal Biopsy Standing lab orders: ____CBC, Creatinine, PT, PTT, Platelet Function Test & UA Radiology Appointment: Imaging Center or ARMC ____ CXR PA/LAT _____ Abd X-ray ____ U/S Renal _____ U/S Renal Biopsy ____ U/S _____________________________________ ____ CT _____________________________________ ____ Other____________________________________ Renal Ultrasound Instructions: Nothing to eat or drink 4hours prior to procedure. Arrive 30 minutes early to register. X-ray Appt: ___________________________________ Renal Biopsy instructions:--See Biopsies done @ ARMC(handout). Arrive 30 minutes early to register. Biopsy Appt: ________________________________ Cardiac Appointment: HOSPITAL USE ONLY ____ Echo ____ Dip/Thal ____ DSE BP Only: _____ Days _____Weeks ____Month Lab Only: _____ Days _____Weeks ____Month Return: _____ Days _____Weeks ____Month _________________________________________ Physician Signature ----------------------- Diagnosis: ____________________________ _______ ____________________________ _______ ____________________________ _______