C1 Esterase Inhibitor Functional

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 Functional
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

C1EST MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

2.5 mL (minimum 0.25 mL)

Cause for Rejection:

Storage:

Frozen

Availability:

Sent to reference lab

Methodology:

Enzyme Immunoassay (EIA)

Special Instructions:

Immediately after drawing specimen place on wet ice.

Lab/Phone:

330-543-8418

TAT:

1-5 days

Additional Info:

Reference range available on patient report

CPT Code:

83520

Synonyms:

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