Pediatric Foods Allergen Profile

Centralized Core Laboratory : 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. Pediatric Foods Allergen Profile
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

PFOOD MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant)tube

Collection Volume:

3.0 mL

Storage:

Refrigerated

Availability:

Sent to Mayo Medical Laboratory

Methodology:

Fluorescence Enzyme Immunoassay (FEIA)

Lab/Phone:

330-543-8418

TAT:

1-3 days

Additional Info:

Reference range is available on patient report.

CPT Code:

86003

Profile Includes:

Milk IgE, Wheat IgE, Peanut IgE, Soybean IgE, Codfish IgE, Corn-Food IgE, Scallop IgE, Shrimp IgE, Walnut-Food IgE, Egg White IgE

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Pediatric Foods Allergen Profile

Centralized Core Laboratory : Immunology

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