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 Peds Profile   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for ALGN Peds Profile
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) by ImmunoCAP

TAT: 1-5 days

Panel Includes: Total IgE; Milk; Wheat; Peanut; Soybean; Fish cod; Egg white; Cat dander; House dust mite ( Dermatophagoides farinae); Cockroach; Dog dander; Mold ( Alternaria alternata)


Lab/Phone: 330-543-8418

Additional Info: Reference Range: Allergen Range: <0.35 kU/L Class Range: 0 IgE: Age: 0-11 Months; Range 0.5-12.0 kU/mL Age: 12-23 Months; Range: 0.5-15.0 kU/mL Age: 2-4 Years; Range: 1.0-35.0 kU/mL Age: 5-9 Years; Range: 2.0-95.0 kU/mL Age: 10-19 Years; Range: 7.0-110.0 kU/mL Age: 20-30 Years; Range: 3.5-58.0 kU/mL Age: 31-50 Years; Range: 5.0-80.0 kU/mL Age: 51-99 Years; Range: 3.0-48.0 kU/mL

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: