Poliovirus Immune Status

Centralized Core Laboratory - Mayo Clinic Laboratories : Send Out

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. Poliovirus Immune Status
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

POLAB

Test Workstation :

MAYO

Specimen Type:

Blood

Tube Type:

Red top(no anticoagulant)tube

Collection Volume:

2.5 mL (minimum 1.5 mL )

Storage:

Refrigerated

Availability:

Sent to Reference lab

Methodology:

Culture/Neutralization

Special Instructions:

Serum gel (SST) tube is also acceptable. Days Performed: Mon, Thur

Lab/Phone:

330-543-8418

TAT:

1-10 days

Additional Info:

Reference Range:

Poliovirus Type 1: < 1:8 titer

Poliovirus Type 3: < 1:8 titer

CPT Code:

86382x2

Synonyms:

Poliovirus Antibody Neutralization Poliovirus (Types 1, 3) Antibodies Neutralization

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Poliovirus Immune Status

Centralized Core Laboratory - Mayo Clinic Laboratories : Send Out

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