Factor XII Activity Assay
| 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. Factor XII Activity Assay | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
F12A
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Lt. Blue top (sodium citrate) tube
Collection Volume:
2.7 mL (minimum 1.8mL) - properly filled tube. Must use appropriate sodium citrate tube based on volume of blood drawn(1.8mL or 2.7mL)
Cause for Rejection:
Grossly hemolyzed, grossly lipemic, grossly icteric. Patient must not be receiving Coumadin or heparin therapy.
Storage:
Spin and freeze immediately. Frozen plasma.
Availability:
Sent to reference lab
Methodology:
Optical Clot-Based
Special Instructions:
Draw one lt. blue top tube per test. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range available on patient report
CPT Code:
85280
Synonyms:
Coagulation Factor XII Activity Assay, Plasma, Factor XII Activity Assay
