Nicotine/Cotinine
| 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. Nicotine/Cotinine | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
NICOT
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
2.0 mL (minimum 1.5 mL)
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Liquid Chromatography -Tandem Mass Spectrometry (LC-MS/MS)
Special Instructions:
Days Performed: MonFri
Lab/Phone:
330-543-8418
TAT:
2-4 days
Additional Info:
Reference range:
Nicotine: <3.0 ng/mL
Cotinine: <3.0 ng/mL
CPT Code:
80323, G0480 (if appropriate)
Panel Includes:
Nicotine, Cotinine
