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Dairy and Grain Allergen Profile

Centralized Core Laboratory : Immunology

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. Dairy and Grain Allergen Profile
2.
3.
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5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

DAGR MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

1.5 mL

Storage:

Refrigerated

Availability:

Sent to Mayo Medical Laboratory

Methodology:

Fluorescence Enzyme Immunassay (FEIA)

Lab/Phone:

330-543-8418

TAT:

1-3 days

Additional Info:

Reference range is available on patient report.

CPT Code:

86003

Panel Includes:

Egg White IgE, Milk IgE, Oat IgE, Wheat IgE, Soybean IgE

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Dairy and Grain Allergen Profile

Centralized Core Laboratory : Immunology

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