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. Mini Rast Allergen Profile   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Mini Rast Allergen Profile
CPT Code: 86003

Specimen Type: Blood

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

Collection Volume: 3.0 mL

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratories

Methodology: Fluorescence Enzyne Immunoassay ( FEIA)

TAT: 1- 3 days

Panel Includes: Cat Epithelium IgE, Short Ragweed IgE, Elm IgE, Oak IgE, English Plantain igE, Bermuda Grass IgE, June Grass IgE, House Dust Mites/D.F. IgE, Alternaria Renuis 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 Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: