Dilantin, Free and Total

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. Dilantin, Free and Total
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

DILFR SUMMA

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

5.0 mL (minimum 3.0 mL)

Cause for Rejection:

Storage:

Refrigerated

Availability:

Sent to reference lab daily

Methodology:

Fluorescent Polarization Immunoassay

Special Instructions:

Lab/Phone:

330-543-8418

TAT:

24 hours

Additional Info:

Reference range is available on patient report

CPT Code:

80186

Synonyms:

Phenytoin Free and Total

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Dilantin, Free and Total

Centralized Core Laboratory : Chemistry

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