We are experiencing exceptionally high volumes in our emergency rooms.
Every patient is important to us, and we are doing all we can to provide care quickly and efficiently.

Clonidine

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. Clonidine
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

CLNID MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube or green top (sodium heparin)tube

Collection Volume:

12.5 mL (minimum 3.0 mL)

Cause for Rejection:

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Liquid Chromatography/Tandem Mass Spectrometry (LCMS)

Special Instructions:

Spin down and send 5.0 mL serum or plasma in a plastic vial.

Lab/Phone:

330-543-8418

TAT:

5-7 days

Additional Info:

Reference range: 1.00-2.00 ng/mL

CPT Code:

80375

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