Felbamate
| 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. Felbamate | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
FELBA
Test Workstation :
Mayo
Specimen Type:
Blood
Tube Type:
Red top Clot tube
Alternate Tube Type:
Gold top SST Gel Tube
Collection Volume:
3.0 mL
Minimum Volume:
1.3 mL
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory: Monday-Friday
Methodology:
High Performance Liquid Chromatography (HPLC)
Special Instructions:
Draw immediately before next scheduled dose.
For Outpatients, test should only be drawn in outpatient locations with a centrifuge.
Centrifuge and aliquot within 2 hours of collection. Aliquot 1.0mL (minimum 0.5mL) serum. Send Refrigerated
Lab/Phone:
330-543-8418
TAT:
1-8 days
CPT Code:
80167
Synonyms:
Felbatol
