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Acetazolamide

Centralized Core Laboratory : Chemistry

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. Acetazolamide
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

ACZ CLEVE

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

6.0 mL (minimum 2.0 mL)

Cause for Rejection:

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

High Performance Liquid Chromatography (HPLC)

Special Instructions:

Do not use serum separator tubes Days Performed: Tuesday, Friday

Lab/Phone:

330-543-8418

TAT:

3-5 days

Additional Info:

Reference range is available on patient report

CPT Code:

80299

Synonyms:

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Acetazolamide

Centralized Core Laboratory : Chemistry

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