West Nile Virus Panel

Infectious Disease Laboratories : Virology

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. West Nile Virus Panel
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

WNILE MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant)

Collection Volume:

1.5 mL (minimum 1.0 mL)

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Enzyme-Linked Immunosorbent Assay (ELISA)

Lab/Phone:

330-543-8576

TAT:

1-4 days

Additional Info:

Reference range:

IgG: Negative

IgM: Negative

CPT Code:

86788, 86789

Panel Includes:

West Nile Virus IgG and West Nile Virus IgM

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