SMA Medical Laboratories
Phone: (215) 322-6590
Toll Free: (877) 697-6252

Fax: (215) 322-9524
Fax: (888) 322-9524

www.smalaboratory.com
940 Pennsylvania Blvd., Unit B, Feasterville, PA 19053
40 Exchange Place, Suite 701, New York, NY 10005
2950 Griffin Road, Dania Beach, FL 33312

MOBILE PHLEBOTOMY FORM
PATIENT INFORMATION
Last Name

First Name

Street Address

Apt#

D.O.B.

SSN

M
F

State

City

Phone

INSURANCE INFORMATION

SPECIMEN INFORMATION
Ordering Physician:
Date of order:

ZIP

I.D.#

Insurance Name

____/____/_______
___________________________________

Bill Medicare

Bill Medicaid

Bill Patient

Bill Client

Requested start date:____/____/_______
Fasting:

Address:____________________________
Date Collected:

____/____/_______

Duplicate report to:__________________________________
___________________________________

Time Collected:____________________ Phone#:_____________________________

Yes
No

Duplicate to Phone#:_________________________________
STAT:

Frequency:_______________________ Fax#:_______________________________ Duplicate to Fax#:___________________________________

ICD9 CODES
See Reverse Side to order only those tests - Any Panel Component diagnosis and treatment of the
It is the ordering party’s responsibility For Panel Description medically necessary for the Can Be Ordered Separately patient.
AFP (Tumor Marker)
SST 1326
Creatinine Urine
U
Lipase
33
SST 1354
Thyroglobulin
SST
Albumin (Alb)
Creatinine Kinase
SST 14
SST 43
SST 34
Lipid Profile
TIBC
SST
Alkaline Phosphatase (ALP) SST 909 dsDNA Autoantibodies
SST 1343
Lyme Screen IgG
SST 943
TOXO IgG
SST
ALT (SGPT)
SST 1330
DHEA-SO4
SST 36
Magnesium Serum
SST 1337
Total IgE
SST
Ammonia, Plasma
L 510
355
Digoxin
Magnesium Urine
U 44
R
Total Protein Serum
SST
Amylase Serum
SST 456
SST 1002
EBV VCA IgM
Microalbumin Urine
U 2000
Total Protein Urine
U
ANA Screen
SST 1344
EBV VCA IgG
SST 457
Microalbumin/Creatinine ratio U 1355
Transferrin
SST
Anti-TPO Ab
SST 200
EBV Early Antigen
SST 458
MMR + V IgG
SST 45
Tryglicerides (Trig)
SST
SST 1102
Anti-TG Ab
EBV Nuclear Antigen
U
SST 459
Non-GYN Cytology, Urine
538
TSH (High Sensitivity)
SST
Apolipoprotein A1
SST 1004
Electrolyte Panel
SST 22
Occult Blood, Feces
FECES 47
Uric Acid Serum
SST
Apolipoprotein B
524
SST 407
ESR or Sedimentation Rate
Phenobarbital
R 51
L
Uric Acid Urine
U
AST (SGOT)
Phenytoin or Dilantin
SST 513
Estradiol
SST 536
R 1005
Urinalysis Complete (dipstick
U
ASO
1007
Fasting Blood Sugar
302
and microscopic)
SST 23
Phosphorus Urine
GR
U
Basic Metabolic Panel
Urinalysis w/reflex to microscopic
SST 514
Ferritin
SST 37
U
SST 1006
Phosphorus Serum
Beta HCG - Serum
Folate
SST 38
Valproic Acid
SST 515
Potassium (K)
SST 1358
R
Fructosamine
Vitamin B12
SST 701
Bilirubin Direct (Dbili)
Green 541
Potassium, Plasma
SST
SST 1332
Vitamin D,25 Hydroxy
SST
Bilirubin Total (Tbili)
Progesterone Total
FSH
SST 6
SST 525
SST 516
PRO-BNP
BUN / Creatinine Ratio
GGT
SST 504
SST
SST 24
CUSTOM DIAGNOSTIC PROFILES
Prolactin
BUN (Urea Nitrogen) S
Glucose Serum
SST 526
SST
SST 25
Prostatic Acid Phosphatase SST 800
3100
300
BUN (Urea Nitrogen) U
Glucose Urine
Allergy Complete Food
U
U
2SST
501
PSA Free
SST 801
Compliment C3
Glyco Hgb A1c and Respiratory Profile
L
SST 401
528
28
PSA Total
SST
HDL
SST
Compliment C4
(102 Specific Allergens)
SST
SST 403
PT/INR
B 107
H.Pylori IgG
CA 15.3
SST 563
L, SST
Anemia Screen
1351
PTH
L
CA - 19.9
Hemoglobin/Hematocrit
SST 100
SST 408
SST
Cardiac Risk Panel I
404
B
PTT
CA - 125
Hepatic Function Panel
SST 29
2SST
Cardiac Risk Panel II
SST 412
L 76
Reticulocyte Cell Count
Calcium Serum
SST 543
SST, L
Hepatitis A IgM Ab
Diabetic Screen
SST 934
SST 105
Rheumatoid Factor
Calcium Urine
U 521