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Fill and Sign the Medical Form PDF Pancare of Florida Inc Pancarefl

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Molecular Detection of Drug Resistance Request Form Laboratory Branch / Division of TB Elimination/ CDC 1600 Clifton Road, Atlanta, GA 30333 Phone 404-639-2455 FAX 404-639-5491 TBLab@cdc.gov Instructions: Please provide the following information and submit the completed form via email to TBLab@cdc.gov or fax at 404-639-5491. An email notification will be provided upon approval with further instructions. Section 1. Laboratory Contact Information Date of Request Submitting Laboratory Contact Name Phone Number Fax Number E-mail Address Section 2. TB Program Contact Information Contact Name Phone Number Fax Number E-mail Address Section 3. Type of specimen Isolate; Specify medium: NAAT+ sediment; Specify specimen source: Section 4. Submission Criteria (check all that apply) Known MDR; Test method: Known RMP resistant; Test method: Contact to known MDR Previously Treated for TB From a country with a high rate of drug resistant TB; Specify: Travel to / lived in a country with a high rate of drug resistant TB; Specify: Mixed culture Non-viable in culture No / poor growth in DST media Other; Explain Has a sample from this patient been previously submitted to CDC? If yes, please provide reason for resubmission: Yes No

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