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C1 Esterase Inhibitor Antigen

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. C1 Esterase Inhibitor Antigen
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

C1ESI MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant tube) tube

Collection Volume:

2.5 mL(minimum 1.5 mL)

Storage:

Frozen

Availability:

Sent to reference lab; Days performed Sun,Wed, Fri

Methodology:

Nephelometry

Special Instructions:

Fasting Preferred but not required.

Lab/Phone:

330-543-8418

TAT:

1-2 days

Additional Info:

Reference range: 19-37 mg/dL

CPT Code:

83883

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