Poliovirus Immune Status
| 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. Poliovirus Immune Status | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
POLAB
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top(no anticoagulant)tube
Collection Volume:
2.5 mL (minimum 1.5 mL )
Storage:
Refrigerated
Availability:
Sent to Reference lab
Methodology:
Culture/Neutralization
Special Instructions:
Serum gel (SST) tube is also acceptable.
Days Performed: Mon, Thur
Lab/Phone:
330-543-8418
TAT:
1-10 days
Additional Info:
Reference Range:
Poliovirus Type 1: < 1:8 titer
Poliovirus Type 3: < 1:8 titer
CPT Code:
86382x2
Synonyms:
Poliovirus Antibody Neutralization
Poliovirus (Types 1, 3) Antibodies Neutralization
