REQUISITION FUNGUS TESTING LABORATORY by xdi18574

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									                                           REQUISITION
                                    FUNGUS TESTING LABORATORY
                            The University of Texas Health Science Center at San Antonio
                                              Department of Pathology
                               7703 Floyd Curl Drive San Antonio, TX 78229-3900
                                      (210) 567-4131 / FAX: (210) 567-4076

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                                         EN1IRONMENTAL CULTURES
                                          C4AIN OF CUSTODY FORM

ProPect Name:                                                    ProPect #:

Individual collecting specimen:


Sample Date             Sample #                      Location                  Sample TypeU                  Area/Volume




SHIPPWD BY:                                                                                       Date:

RWCWIVWD BY:                                                                                      Date:
                                          FTL Staff

6Sample T<pe=

        Bul[                       Material for fungal ]uantitation and culture ($75.00/sample)
        Air Plate                  Plates from Anderson sampler or other air sampling e]uipment ($75.00/sample)
        Settling Plates            Plates from settling studies ($75.00/sample)

        CAP# 21433-01         MCR # CLO523 MCD# LO4585235              CLIA 45D0660483   TAX ID# 74-1586031

                                       BILLING TO INSTITUTIONS AND PHYSICIANS ONLY

								
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