Celiac HLA-DQ Typing
| 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. Celiac HLA-DQ Typing | |
| 2. | |
| 3. | |
| 4. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
CELGN
Test Workstation :
MAYO
Specimen Type:
Whole Blood
Tube Type:
Yellow Top (ACD) tube
Collection Volume:
6.0 mL
Minimum Volume:
3.0 mL
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Polymerase Chain Reaction (PCR)/Sequence-Specific Oligonucleotide Probe (SSO)
Special Instructions:
Do not transfer blood to other containers
Lab/Phone:
330-543-8418
TAT:
5-9 days
CPT Code:
81376 x2
