Somatostatin
| 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. Somatostatin | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
SOMAT
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Call lab- Mayo Misc. Tube- GI Preservative
Collection Volume:
10.0 mL (minimum 3.0 mL)
Cause for Rejection:
Mild Hemolysis, Mild Lipemia
Storage:
Critical Frozen
Availability:
Sent to reference lab
Methodology:
Direct Radioimmunoassay (RIA)
Special Instructions:
Collect 10.0 mL of blood in special tube containing G.I Preservative (Mayo Supply number T125). Specimen should be separated and 3.0 mL plasma frozen as soon as possible.
1. Patient should be fasting 1012 hours prior to collection.
2. Patient should not be on any antacid medication or medications that affect insulin secretion or intestinal motility, if possible, for at least 48 hours prior to collection.
For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).
Lab/Phone:
330-543-8418
TAT:
7-11 days
Additional Info:
Reference range available on report
CPT Code:
84307
