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. Respiratory 28 Allergen Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Respiratory 28 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 Enzyne Immunoassay ( FEIA)

TAT: 1-3 days

Panel Includes: Cat Epithelium IgE, Short Ragweed IgE, Mountain Cedar IgE, Elm IgE, Oak IgE, Silver Birch IgE, Russian Thistle IgE, Cockroach IgE, Rough Marsh Elder IgE, White Hickory IgE, Easter Sycamore IgE, Rough Pigweed IgE, White Ash IgE, Walnut IgE, Nettle IgE, Red Sorrel IgE, Cottonwood IgE, Mulberry IgE, Boxelder-Maple IgE, Timothy Grass IgE, Bermuda Grass igE, House Dust Mites/D.P. IgE, House Dust Mites/D.F. IgE, Alternaria Tenuis IgE, Aspergillus Fumigatus IgE, Cladsporium IgE, Penicillium IgE, Dog Dander 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: