|
Reason for Visit:
|
|
|
Date of Collection:
|
Time of Collection:
|
|
Time of last dose:
|
|
|
Fasting Lab:
|
Collected Off Site:
|
|
Urine Collection:
|
Pharmacogenetic Testing buccal swab collected:
|
|
Saliva Point of Care for Alcohol
|
|
|
Reason for Test:
|
Results of POC ETOH:
|
|
Testing Device Name:
|
LOT#:
|
|
Expiration Date:
|
|
|
Lab orders-tests:
• • •
|
|
|
Who
|
Site of draw was the:
• • •
|
|
Attempts:
|
Order Placed:
|
|
Lab Comments or other orders:
|
|
|
Discharge
|
|
|
State at Discharge:
|
|
|
Time with patient:
|
|
