IgG Subclasses
| 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. IgG Subclasses | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
IGGSU
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red Top (no anticoagulant) tube
Collection Volume:
2.5 mL (minimum 1.5 mL)
Cause for Rejection:
Gross Hemolysis, Gross lipemia
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Turbidimetry
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Ref. range is age dependent; avail on patient report
CPT Code:
82784, 82787 x 4
Panel Includes:
Total IgG,
IgG Subclass 1,
IgG Subclass 2,
IgG Subclass 3, and
IgG Subclass 4
