Southern Ohio Allergen Panel

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. Southern Ohio Allergen Panel
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

OSOTH

Test Workstation :

MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

6.0 mL

Minimum Volume:

5.0 mL

Storage:

Refrigerated

Availability:

Sent to Mayo Medical Laboratories

Methodology:

Fluorescence Enzyne Immunoassay ( FEIA)

Lab/Phone:

330-543-8418

TAT:

1-3 days

CPT Code:

86003

Panel Includes:

Cat Epithelium IgE, Short Ragweed IgE, Elm IgE, Oak IgE, Lamb's Quarters IgE, Cockroach IgE, White Hickory IgE, Walnut Tree IgE, Bermuda Grass IgE, June Grass IgE, Johnson Grass IgE, House Dust Mites/D.P. IgE, House Dust mites/D.F. IgE, Alternaria Tenuis IgE, Aspergillus Fumigatus IgE, Cladosporium IgE, Dog Dander IgE

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Southern Ohio Allergen Panel

Centralized Core Laboratory - Mayo Clinic Laboratories : Send Out

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