Methotrexate
| 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. Methotrexate | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
MTX
Test Workstation :
ACHM5
Specimen Type:
Blood
Tube Type:
Green top (lithium) heparin tube
Minimum Volume:
500 uL
Preferred Volume:
1.5 mL
Storage:
Shipping- Send Refrigerated; Storage-Refrigerated: 2 weeks; Frozen: up to 3 freeze/thaw cycles @ -10 degrees Celsius
Availability:
24 hours/day, 7 days/week
Methodology:
Roche-Homogeneous Immunoassay
Lab/Phone:
330-543-8418
TAT:
4 hours
Additional Info:
Reference range:
Following a 4-6 hour infusion a patient with a 24 hr serum concentration of >5-10 umol/L, a 48 hr level of > 0.5-1.0 umol/L or a 72 hr level >0.2 umol/L is at increased risk for toxicity if conventional low dose leucovorin rescue is given.
CPT Code:
80204
Synonyms:
Mexate
