Cystinuria Profile, QN, Random

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. Cystinuria Profile, QN, Random
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

CYSU

Test Workstation :

MAYO

Specimen Type:

Urine

Tube Type:

Urine Container

Collection Volume:

2.0 mL (minimum 0.5 mL)

Storage:

Frozen

Availability:

Sent to Mayo Medical Laboratory

Methodology:

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

Lab/Phone:

330-543-8418

TAT:

3-5 days

Additional Info:

Reference Range available on patient report

CPT Code:

82136