Clobazam and metabolite, S

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. Clobazam and metabolite, S
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CLBZS MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

1.25 mL minimum 1.0 mL

Storage:

Refrigerated

Methodology:

Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Lab/Phone:

330-543-8418

TAT:

1-5 days

Additional Info:

Reference Range: Clobazam

Therapeutic Range: 30-300 ng/mL

Norclobazam

Therapeutic Range: 300-3,000 ng/mL

CPT Code:

80339

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