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. Eosinophilic Allergen Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Eosinophilic 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 Laboratory

Methodology: Fluorescence Enzyme Immunoassay (FEIA)

TAT: 1-3 days

Panel Includes: Beef IgE, Chicken IgE, Lamb IgE, Pork IgE, Turkey IgE, Banana IgE, Oat IgE, Milk IgE, Egg White IgE, Egg Yolk IgE, Wheat IgE, Peanut IgE, Peach IgE, Rice IgE, Codfish IgE, Shrimp IgE, Soybean IgE, Corn-Food IgE, Tomato IgE, Rye IgE, Green String Bean, IgE, Squash IgE, White Potato IgE, Apple IgE, Barley 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: