IBD sgi Diagnostic

Infectious Disease Laboratories : 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. IBD sgi Diagnostic
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube AND lavender(EDTA) tube

Collection Volume:

5.0 mL Red Top - Serum and 2.0 mL Lavender Top (EDTA) - Whole Blood

Cause for Rejection:

Must have both Red top and Lavender top

Storage:

Refrigerate

Availability:

Sent to Reference Laboratory

Methodology:

A quantitative analysis of serologic, genetic and inflammation markers combined with the Prometheus Smart Diagnostic Algorithm (pattern-recognition technology) for IBD prediction and differentiation

Special Instructions:

Send to Prometheus lab. Lab - catalog number 1800

Lab/Phone:

330-543-8418

TAT:

3-4 days

CPT Code:

83520x6, 82397x4,86140,88346,88350,81479x4

Panel Includes:

ASCA IgA ELISA, ASCA IgG ELISA, Anti-OmpC IgA ELISA, Anti-CBir1 IgG ELISA, Anti-A4-Fla2 IgG ELISA, Anti-FlaX IgG ELISA, IBD-specific pANCA, AutoAntibody ELISA, IF A Perinuclear Pattern, DNAse Sensitivity, ATG16L1 (SNP (rs2241880), ECM1 (SNP (rs3737240), NKX2-3 (SNP (rs10883365 ), STAT3 (SNP (rs744166), ICAM-1, VCAM-1, VEGF, CRP, SAA