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. ALGN Food Adult/Child   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for ALGN Food Adult/Child
CPT Code: 86003 (x11)

Specimen Type: Blood

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

Collection Volume: 4 mL

Storage: Refrigerated

Availability: Sent to Reference laboratory

Methodology: Fluorescent Enzyme Immunoassay ( FEIA ) ImmunoCap

Special Instructions: This panel is recommended for children 3 years and older.

TAT: 1-5 days

Panel Includes: Milk; Wheat; Peanut; Soybean; Fish cod; Clam; Maize corn; Scallop; Shrimp; Walnut; Eggwhite


Lab/Phone: 330-543-8418

Additional Info: Reference range: Allergen: Range: <0.35 KU/L Class: Range: 0 Days Performed: Tue, Thur, Fri

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: