Felbamate

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. Felbamate
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

FELBA CLEVE

Specimen Type:

Blood

Tube Type:

Green top (lithium or sodium heparin) tube

Collection Volume:

5.0 mL (minimum 0.5 mL)

Cause for Rejection:

Storage:

Frozen

Availability:

Sent to reference lab; days performed Fri

Methodology:

High Performance Liquid Chromatography (HPLC)

Special Instructions:

Collect immediately prior to next dose.

Lab/Phone:

330-543-8418

TAT:

1-8 days

Additional Info:

Reference range: 30.0-60.0 ug/mL

CPT Code:

80339

Synonyms:

Felbatol

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Felbamate

Centralized Core Laboratory : Chemistry

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