Northeast Regional Allergen Profile
| 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. Northeast Regional Allergen Profile | |
| 2. | |
| 3. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
NEREG
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top ( no anticoagulant) tube
Collection Volume:
3.0 mL
Minimum Volume:
2.5 ml
Storage:
Refrigerated
Availability:
Sent to Mayo Medical Laboratory
Methodology:
Fluorescence Enzyme Immunassay (FEIA)
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range is available on patient report
CPT Code:
86003
Panel Includes:
Oak IgE, June Grass IgE, Lamb's Quarter IgE, Dog Dander IgE, Cladosporium IgE, Timothy Grass IgE, Short Ragweed IgE, Cat Epithelium IgE, Alternaria tenuis IgE, House Dust Mites/D. farinae
