Non-Seasonal Inhalant Allergen Profile
| 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. Non-Seasonal Inhalant Allergen Profile | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
NSIP
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant)tube
Collection Volume:
3.0 mL
Minimum Volume:
2.5 ml
Storage:
Refrigerated
Availability:
Sento to Mayo Medical Laboratory
Methodology:
Fluorescence Enzyme Immunoassay (FEIA)
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range is available on patient report
CPT Code:
86003
Panel Includes:
Cat epithelium IgE, Dog Dander IgE, Penicillium Chrysogenum IgE, A. fumigatas IgE, Alternaria tenuis IgE, Cladosporium IgE, House Dust/Greer Lab IgE, House Dust/H-S Lab IgE, House Dust Mites/D. pteronyssinus, House Dust Mites/D. farinae
