Ativan

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. Ativan
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

ATVAN CLEVE

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

5.0 mL (minimum 1.5 mL)

Cause for Rejection:

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Special Instructions:

Do not use serum separator tubes.

Lab/Phone:

330-543-8418

TAT:

6-11 days

Additional Info:

Therapeutic range:

50-240 ng/mL

Toxic: >300 ng/mL

CPT Code:

80154

Synonyms:

Lorazepam

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