Ohio Trees 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 Trees Allergen Panel | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
OTREE
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 Laboratory
Methodology:
Fluorescence Enzyne 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:
Sweet Gum IgE, Mountain Cedar IgE, Beech IgE, Hazelnut IgE, Elm IgE, Oak IgE, Silver Birch IgE, White Hickory IgE, Eastern Sycamore IgE, White Pine IgE, White Ash IgE, Willow IgE, Walnut IgE, Cottonwood IgE, Privet Tree IgE, Mulberry IgE, Boxelder-Maple IgE
