C1 Esterase Inhibitor Functional
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. C1 Esterase Inhibitor Functional | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
C1EST
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
2.5 mL
Minimum Volume:
1.5 mL
Storage:
Strict Frozen
Availability:
Sent to reference lab
Methodology:
Enzyme Immunoassay (EIA)
Special Instructions:
Immediately after drawing specimen place on wet ice.
Lab/Phone:
330-543-8418
TAT:
1-5 days
Additional Info:
Reference range available on patient report
CPT Code:
83520
