Calprotectin
| 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. Calprotectin | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
CALPR
Test Workstation :
MAYO
Specimen Type:
Stool
Tube Type:
Stool container
Collection Volume:
Random stool collection- 5 grams
Minimum Volume:
1 gm
Cause for Rejection:
Specimen collected in diaper
Storage:
Frozen
Availability:
Sent to reference lab; Days performed M-F
Methodology:
Enzyme Linked Immunosorbent Assay (ELISA)
Special Instructions:
Please indicate collection date and time. Specimens may be stored refrigerate for up to 72 hours following collection. Specimens must be frozen within 72 hours of collection and remain frozen throughout the shipping process.
Lab/Phone:
330-543-8418
TAT:
3-5 days
Additional Info:
Reference Values:
< 50.0 mcg/g (Normal);
50.0-120 mcg/g (Borderline);
> 120 mcg/g (Abnormal);
Reference values apply to all ages.
CPT Code:
83993
