Ambien
| 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. Ambien | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
AMB
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) or Green top (sodium heparin) tube
Collection Volume:
5.0 mL
Minimum Volume:
1.0 mL
Cause for Rejection:
Collected in Get Tube
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Liquid Chromatography/Tandem Mass Spectrometry (LC/MS/MS)
Lab/Phone:
330-543-8377
TAT:
3-5 days
Additional Info:
Therapeutic range is available on patient report
CPT Code:
80368
Synonyms:
Zolpidem
