TORCH IgM Panel

Centralized Core 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. TORCH IgM Panel
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

TRCHM / MAYO, CLEVE

Specimen Type:

Blood

Tube Type:

Red Top (no anticoagulant) tube

Collection Volume:

11.0 mL (minimum 5.5 mL)

Storage:

Refrigerated

Availability:

Sent to Reference Laboratory

Methodology:

Varies by test

Lab/Phone:

330-543-8418

TAT:

Varies by test

Additional Info:

See Patient Report for Reference Values.

CPT Code:

86778, 86645, 86694, 86762

Panel Includes:

Toxoplasma IgM Ab CMV IgM Ab HSV IgM Ab Rubella IgM Ab

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