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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 ____________________________________
                  ____________________________________...