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. Northeast Regional Allergen Profile   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Blood

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

Collection Volume: 2.0 mL

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratory

Methodology: Fluorescence Enzyme Immunassay (FEIA)

TAT: 1-3 days

Panel Includes: Oak IgE, June Grass IgE, Lamb's Quarter IgE, Dog Dander IgE, Cladosporium IgE, Timothy Grass IgE, Short Ragweed IgE, Cat Epithelium IgE, Alternaria tenuis IgE, House Dust Mites/D. farinae


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: