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. Inhalant 24 Allergen Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Inhalant 24 Allergen Panel
CPT Code: 86003

Specimen Type: Blood

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

Collection Volume: 6.0 mL

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratory

Methodology: Fluorescence Enzyne Immunoassay ( FEIA)

TAT: 1-3 days

Panel Includes: Alternaria Tenuis IgE, Aspergillus Fumigatus IgE, Bermuda Grass IgE, Box Elder/Maple,S IgE, Cat Epithelium IgE, Cladsporium IgE, Cocklebur IgE, Cocroach IgE, Cottonwood IgE, Dog Dander IgE, Eastern Sycamore IgE, Elm IgE, House Dust Mites/ D.F. IgE, House Dust Nites/D.P. IgE, Johnson Grass IgE, June Grass IgE, Lamb's Quarter IgE, Mugwort IgE, Nettle IgE, Oak IgE, Rough Marsh Elder IgE, Silver Birch IgE, Short Ragweed IgE, Walnut Tree IgE, White Ash 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: