Cheese, Mold, IgE
| 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. Cheese, Mold, IgE | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
MCHZ
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
0.9 mL for 1 allergen; 1.5 mL for every 5 allergens
Minimum Volume:
0.75 mL for 1 allergen; 1.2 mL for every 5 allergens
Storage:
Refrigerated
Availability:
Sent to Mayo Medical Laboratory
Methodology:
Fluorescence Enzyme Immunoassay (FEIA)
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range is available on patient report
CPT Code:
86003
