Celiac HLA-DQ Typing

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. Celiac HLA-DQ Typing
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CELGN MAYO

Specimen Type:

Whole Blood

Tube Type:

Yellow Top (ACD) tube

Collection Volume:

6.0 mL (minimum 3.0 mL)

Storage:

Refrigerated

Availability:

Sent to Reference Laboratory

Methodology:

Polymerase Chain Reaction (PCR)/Sequence-Specific Oligonucleotide Probe (SSO)

Special Instructions:

Do not transfer blood to other containers

Lab/Phone:

330-543-8418

TAT:

5-9 days

CPT Code:

81376 x2

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