Phenobarbital

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. Phenobarbital
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

PHNO MACH1

Specimen Type:

Blood

Tube Type:

Green top (lithium heparin) tube

Collection Volume:

0.5mL

Storage:

Frozen

Availability:

Daily, 24 hours STAT

Methodology:

Fluorescence Polarization

Special Instructions:

For therapeutic monitoring, draw peak levels 2 hours post-IV injection or 12 hours post-oral ingestion and trough levels immediately prior to next dose. Please indicate whether the specimen is a peak, trough, or random level.

Lab/Phone:

330-746-9623

TAT:

1 hour

Additional Info:

Therapeutic range: 15-40 ug/mL

CPT Code:

80184

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Phenobarbital

Laboratory : Chemistry

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