Zonisamide
| 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. Zonisamide | |
| 2. | |
| 3. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
ZONIS
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Blood-Red Top (no anticoagulant) tube
Collection Volume:
2.5 mL
Minimum Volume:
1.5 mL
Cause for Rejection:
SST tube; Gross hemolysis, Gross lipemia, Grossly icteric
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Liquid Chromatography-Tandem mass Spectrometry (LC-MS/MS)
Special Instructions:
Sent to Reference Laboratory. Performed MonSat.
BloodRed Top (no anticoagulant) tube 2.5 mL (minimum 1.5 mL)
Lab/Phone:
330-543-8418
TAT:
1-5 days
Additional Info:
Reference range: 10.0-40.0 ug/mL
CPT Code:
80203
Synonyms:
Zonegran
