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 Trees Allergen Panel   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Blood

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

Collection Volume: 4.5 mL

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratory

Methodology: Fluorescence Enzyne Immunoassay ( FEIA)

TAT: 1-3 days

Panel Includes: Sweet Gum IgE, Mountain Cedar IgE, Beech IgE, Hazelnut IgE, Elm IgE, Oak IgE, Silver Birch IgE, White Hickory IgE, Eastern Sycamore IgE, White Pine IgE, White Ash IgE, Willow IgE, Walnut IgE, Cottonwood IgE, Privet Tree IgE, Mulberry IgE, Boxelder-Maple 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: