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. Ohio Grasses Allergen Panel   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Blood

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

Collection Volume: 4.25 mL

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratories

Methodology: Fluorescence Enzyme Immunoassay ( FEIA)

TAT: 1-3 days

Panel Includes: Short Ragweed IgE, Russian Thistle IgE, Lamb's Quarters IgE, Mugwort IgE, Giant Ragweed IgE, English Plantain IgE, Rough Pigweed IgE, Nettle IgE, Firebush IgE, Red Sorrel IgE, Cocklebur IgE, Timothy Grass IgE, Bermuda Grass IgE, Johnson Grass IgE, Ry Grass IgE, Sweet Vernal Grass 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: