Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


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. Food 27 Allergen Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Food 27 Allergen Panel
CPT Code: 86003

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 6.5 mL

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratories

Methodology: Fluorescence Enzyne Immunoassay ( FEIA)

TAT: 1-3 days

Panel Includes: Banana IgE, Beef IgE, Milk IgE, Chicken IgE, Cacao/Cocoa IgE, Cinnamon IgE, Codfish IgE, Corn-Food IgE, Egg white IgE, Egg Yolk IgE, Garlic IgE, Green Pea IgE, Baker's Yeast IgE, Mustard IgE, Orange IgE, Peanut IgE, Pork IgE, Rice IgE, Scallop IgE, Shrimp IgE, Soybean IgE, Strawberry Ige, Tomato IgE, Tuna IgE, Walnut - Food IgE, Wheat Ige, White Potato IgE


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: