CU Index

Centralized Core Laboratory : Immunology

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. CU Index
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CUI MAYO

Specimen Type:

Blood

Tube Type:

Red top ( no anticoagulant) tube

Collection Volume:

5.0 mL (minimum 1.5 mL)

Storage:

Ambient

Availability:

Days Performed Mon-Wed-Fri

Methodology:

Ex Vivo Challenge, Cell Culture and Histamine Analysis

Special Instructions:

Draw blood in a plain, red-top tube(s), allow clotting. Spin down and separate within 2 hours. Send 2 mL of serum at room temperature in a plastic vial. Note: Patients taking calcineurin inhibitors should stop medication 72 hours prior to draw. Patients taking prednisone should be off their medication for 2 weeks prior to draw. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

Lab/Phone:

330-543-8417

TAT:

2-5 days

Additional Info:

Reference range: <10.0

CPT Code:

86343