Ohio Grasses Allergen Panel
| 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. Ohio Grasses Allergen Panel | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
OGRAS
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
6.0 mL
Minimum Volume:
5.0 mL
Storage:
Refrigerated
Availability:
Sent to Mayo Medical Laboratories
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:
Short Ragweed IgE, Russian Thistle IgE, Lamb's Quarters IgE, Mugwort IgE, Giant Ragweed IgE, English Plantain IgE, Rough Pigweed IgE, Nettle IgE, Firebush IgE, Red Sorrel IgE, Cocklebur IgE, Timothy Grass IgE, Bermuda Grass IgE, Johnson Grass IgE, Ry Grass IgE, Sweet Vernal Grass IgE
