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Mycobacteriology Laboratory

Enrollment for Tuberculosis 'Fast Track' Testing

Respiratory Specimens Only
'Working Together for Public Health in New York'

Institution's Name

Address



City

State

 

Zip Code

Laboratory Director (Name)

Phone # for Reports

Confidential FAX # for Reports

Off-hours/Weekends Phone #

Off-hours/Weekends FAX #

Authorized person to receive lab reports if different from lab director

Name of person to be contacted regarding specimen

Phone # of Contact Person

Infection Control Professional's Name

Phone # of Infection Control Professional

FAX # of Infection Control Professional

Email Address of Infection Control Professional

The laboratory director understands the following requirements:
  1. The patient must be newly diagnosed from an AFB-positive respiratory specimen.
  2. Only one specimen per patient may be submitted.
  3. The patient history form must be filled out completely.
  4. The specimen should be sent by express mail or courier.

Final Step: Submit your Enrollment Form or reset/clear this form.