llergen est Reuest...May o Medical Laborator ies llergen est Reuest MML Internal Use Only Cre T236...
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Mayo Medical Laboratories Allergen Test Request MML Internal Use Only MC0767-08rev0618 T236 ©2018 Mayo Foundation for Medical Education and Research Page 1 of 9 Patient Information (required) Patient ID (Medical Record No.) Patient Name (Last, First, Middle) Gender Male Female Birth Date (mm-dd-yyyy) Collection Date (mm-dd-yyyy) Time am pm Client Information (required) Client Name Client ID Client Phone Client Order No. Street Address City State ZIP Code Submitting Physician/Physician Name Information (required) Submitting/Referring Physician (Last, First) Fill in only if Call Back is required. Phone ( ) _______ - _________ Fax* ( ) _______ - _________ *Fax number given must be from a fax machine that complies with applicable HIPAA regulation. Reason for Referral (required) ICD-10 Diagnosis Code Ship specimens to: Mayo Medical Laboratories 3050 Superior Drive NW Rochester, MN 55901 Customer Service: 800-533-1710 Billing Information • An itemized invoice will be sent each month. • Payment terms are net 30 days. Call the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US) Visit www.MayoMedicalLaboratories.com for the most up-to-date test and shipping information. Note: It is the client’s responsibility to maintain documentation of the order.
Transcript of llergen est Reuest...May o Medical Laborator ies llergen est Reuest MML Internal Use Only Cre T236...
Mayo Medical LaboratoriesAllergen Test Request
MML Internal Use Only
MC0767-08rev0618
T236
©2018 Mayo Foundation for Medical Education and Research Page 1 of 9
Patient Information (required)Patient ID (Medical Record No.) Patient Name (Last, First, Middle)
Gender Male Female
Birth Date (mm-dd-yyyy) Collection Date (mm-dd-yyyy) Time am pm
Client Information (required)Client Name Client ID Client Phone Client Order No.
Street Address City State ZIP Code
Submitting Physician/Physician Name Information (required)Submitting/Referring Physician (Last, First) Fill in only if Call Back is required.
Phone ( ) _______ - _________
Fax* ( ) _______ - _________
*Fax number given must be from a fax machine that complies with applicable HIPAA regulation.
Reason for Referral (required)
ICD-10 Diagnosis Code
Ship specimens to:Mayo Medical Laboratories3050 Superior Drive NWRochester, MN 55901
Customer Service: 800-533-1710
Billing Information• An itemized invoice will be sent each month.• Payment terms are net 30 days.
Call the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US)
Visit www.MayoMedicalLaboratories.com for the most up-to-date test and shipping information.
Note: It is the client’s responsibility to maintain documentation of the order.
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
MC0767-08rev0618
T236
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Animals (Epithelia and Proteins)BOV Bovine Serum AlbuminBDRP Budgerigar Droppings BFTH Budgerigar Feathers CFTH Canary Feathers CAT Cat Epithelium CDROP Chicken Droppings CHCK Chicken Feathers CSPR Chicken Serum Proteins COW Cow Epithelium DEEP Deer Epithelium DOGD Dog Dander DUCK Duck Feathers FEEP Ferret Epithelium FINCH Finch Feathers GERB Gerbil Epithelium GOAT Goat Epithelium GOOS Goose Feathers GUIN Guinea Pig Epithelium HEPI Hamster Epithelium HORS Horse Dander HSPR Horse Serum Proteins MOUS Mouse Epithelium MOSP Mouse Serum Protein MOUP Mouse Urine Protein PIGF Pigeon Feathers PIGE Pig Epithelium REPII Rabbit Epithelium RSER Rabbit Serum ProteinsRUPR Rabbit Urine ProteinsRAT Rat Epithelium RTSP Rat Serum ProteinRTUP Rat Urine ProteinSHWL Sheep Wool TURKF Turkey Feathers
AntibioticsAMOXY AmoxicillinPBPO Penicillin GPENIV Penicillin V
DrugsRACTH Adrenocorticotropic Hormone, ACTHBREG Beef Neutral-Regular InsulinCHYM ChymopapainINHU Insulin (Human)PREGI Pork Neutral-Regular InsulinTTOX Tetanus Toxoid
Food–DairyALFA Alpha-LactoalbuminBLAC Beta-LactoglobulinCASE CaseinCCHZ Cheese, CheddarMCHZ Cheese, MoldEGG Egg WhiteYOLK Egg YolkMILK MilkGMILK Milk, Goat’sMARE Milk, Mare’sPMLK Milk, ProcessedOVAL OvalbuminOVMU OvomucoidWHEY Whey
Food–FishANCH AnchovyMUSS Blue MusselCLAM ClamCOD CodfishCRAB CrabCRAY CrayfishHAKE Hake, Fish HALI HalibutHERR HerringLANG Langust (Lobster) LOB LobsterMACK Mackerel CHUB Mackerel, Chub JMACK Mackerel, Jack MEGR MegrimOYST OysterPLAI PlaiceSALM SalmonSARD Sardine (Pilchard) SCALS ScallopSHRI ShrimpSOLEF SoleSQUID SquidSQUI Squid, Pacific SWORD SwordfishTROT Trout TUNA Tuna
Food–FruitAPPL AppleAPR ApricotAVOC AvocadoBANA BananaBLACK BlackberryBLUE BlueberryCAROB CarobCHER CherryCCNT CoconutCRANB CranberryDATE Date, FruitGRAP GrapeGRFR GrapefruitGUAV GuavaJACK Jack FruitKIWI Kiwi FruitLEM LemonLIME LimeMAND MandarinMANGO MangoMELN MelonsORNG OrangePAPY PapayaPFRUT Passion FruitPECH PeachPEAR PearPERS PersimmonPNAP PineapplePLUM PlumRASP RaspberryRECR Red CurrantSTBY StrawberryWMEL Watermelon
Food–GrainsBRLY BarleyBUCW BuckwheatGLT GlutenHOP Hop FruitMALT MaltCMIL Millet, CommonFMIL Millet, FoxtailJMIL Millet, JapaneseOATS OatPUSE Pumpkin SeedRASE Rape SeedRICE RiceRYE RyeSOY SoybeanSBSE Sugarbeet SeedSUNFS Sunflower SeedWHT Wheat
Food–MeatsBEEF BeefCHIC ChickenHORM Horse MeatLAMB LambOCTO OctopusPORK PorkRAMB Rabbit MeatTURK Turkey
Food–MiscellaneousBYST Baker’s YeastCOCOA Cacao/CocoaGELA GelatinGUM Gum ArabicGGUM Gum GuarHUNY HoneyLINS LinseedMUSH MushroomSNAIL SnailTEA TeaTRAG Tragacanth
Food–NutsALM AlmondBRAZ Brazil NutCASH CashewCNUT Chestnut, SweetNUTH Hazelnut-FoodPEAN PeanutPEC Pecan-FoodPINE Pine NutPISTA PistachioBLW Walnut-Food
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
MC0767-08rev0618
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Food–Spices/CondimentsANSE AniseBASL BasilBAYL Bay LeafBLPEP Black/White PepperCWAY CarawayCARD CardamomCHILI Chili PepperCINN CinnamonCLOV CloveCORI CorianderCURR CurryDILL DillFESE Fennel SeedGARL GarlicGING GingerGRFE Greek FennelMACE MaceMARJ MarjoramMSTD MustardNMEG NutmegOREG OreganoPAPR PaprikaCHILI Pepper, ChiliPOPSD Poppy SeedSESA Sesame SeedTARR TarragonTHYM ThymeVANIL Vanilla
Food–VegetablesASPAR AsparagusBAMB Bamboo ShootGSTB Bean, Green StringKIDBN Bean, Kidney (Red)BENW Bean, WhiteBEETS Beets (Beetroot)BROC BroccoliBSPR Brussel SproutsCABB CabbageCROT CarrotCALFL CauliflowerCELY CeleryCHXP Chick PeaCORN Corn-FoodCUKE CucumberEGGP EggplantLEN LentilLETT LettuceOLIVF Olive-FoodONIN OnionPAPR PaprikaPSLY ParsleyCHXP Pea, ChickGPEA Pea, GreenSPOT Potato, SweetPOTA Potato, WhiteSPIN SpinachSQUA SquashTOMA Tomato
GrassesBAHG Bahia GrassBGRS Barley GrassBERG Bermuda GrassBROM Brome GrassCAGR Canary GrassREED Common ReedCRNP Corn PollenOATC Cultivated OatCRYE Cultivated RyeWHTC Cultivated WheatFOGT False Oat GrassJOHN Johnson GrassJUNE June GrassMEAD Meadow FescueMFOX Meadow FoxtailORCH Orchard GrassREDT Red TopRYEG Rye GrassSAGR Salt GrassVERG Sweet Vernal GrassTIMG Timothy GrassVELV Velvet LeafWRGR Wild Rye Grass
House DustHDG House Dust/Greer LabHDHS House Dust/H-S Lab
House Dust MitesACAR Acarus siroBTROP Blomia tropicalisDMIC Dermatophatoides microcerasDF House Dust Mites/Dermatophagoides farinae
DP House Dust Mites/Dermatophagoides pteronyssinus
EMAY Euroglyphus mayneiGDOM Glycyphagus domesticusLEPD Lepidoglyphus destructorTRYPI Tyrophagus putrescentiae
Insects–VenomsHBV Honeybee VenomWSPV Wasp VenomWFHV White Faced Hornet VenomYFHV Yellow Faced Hornet VenomYJV Yellow Jacket Venom
Insects–Whole BodiesBBEET Berlin BeetleBWOR Blood WormCOCR CockroachEHOR European HornetFANT Fire AntGWEE Grain WeevilHFSF Horsefly/Stable flyMSPP Mosquito speciesMOTH Moth
IsocyanateIHDI Isocyanate HDIIMDI Isocyanate MDIITDT Isocyanate TDI
MiscellaneousSMFL Seminal Fluid
MoldsALTN Alternaria tenuisASP Aspergillus fumigatusASPG Aspergillus nigerAUPU Aureobasidium pullulansBOT Botrytis cinereaCDAB Candida albicans (Monilia)CEAC Cephalosporium acremoniumCHGL Chaetomium globosumCLAD CladosporiumCURL Curvularia lunataEPUR Epicoccum purpurascensFUSM Fusarium moniliformeHELM Helminthosporium halodesMUC MucorPENL Penicillium chrysogenumPHMA Phoma betaePIOR Pityrosporum orbiculareRHNI Rhizopus nigricansSTEM StemphylliumTRVI Trichoderma virideTCPT Trichophyton rubrumTRPU Trichosporon pullulansULCH Ulocladium chartarumUSNU Ustilago nuda, Mold Grain Rust
OccupationalAAMY Alpha-AmylaseCBN Castor BeanCOTT Cotton FiberCSED CottonseedEOXD Ethylene OxideFRMH FormaldehydeGCBN Green Coffee BeanGPEP Green PepperHEXAI Hexahydropthalic AnhydrideISPG IspaghulaLATX LatexLYSO LysozymeMAAN Maleic AnhydridePAPN PapainPAHD Phthalic AnhydrideSILK SilkWSLK Silk, WildTOBAC TobaccoTMA Trimellitic Anhydride, TMA
ParasitesANISP Anisakis, ParasiteASCRI Ascaris
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
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TreesACAC AcaciaBCYP Bald CypressBECH BeechBXMPL Box Elder/MapleCEDR CedarJCEDR Cedar, JapaneseCED Cedar, MountainCTRE Chestnut TreeCTWD CottonwoodDATRE Date, TreeDFIR Douglas FirESYC Eastern SycamoreELDR ElderELM ElmEUCL EucalyptusALDR Grey AlderHAZ Hazelnut-TreePCANH Hickory PecanWHIC Hickory, WhiteHBEA Horn BeamLIND LindenMELAI Melaleuca leucadendronMESQ MesquiteMULB MulberryOAK OakOLIV Olive TreeAPIN Pine, AustralianWPIN Pine, WhitePTRE Privet TreeQPALM Queen PalmBIR Silver BirchSPRU SpruceSGUM Sweet GumWALN Walnut TreeASHW White AshWILL Willow
WeedsCBUR CockleburOXI Daisy, Ox-EyeDAND DandelionELDR ElderMARS Elder, Rough MarshEGPL English PlantainFBSH Firebush (Kochia)GLDR GoldenrodLAMQ Lamb’s QuarterLUPN LupinMUG MugwortNETT NettlePJUD Parietaria judaicaPOFF Parietaria officinalisRRRP Rough PigweedFRW Ragweed, FalseGRW Ragweed, GiantSRW Ragweed, ShortWRW Ragweed, WesternRWEED Rape WeedSORR Red SorrelRUSS Russian ThistleSCLE ScaleSBWE Sugarbeet WeedSUNF Sunflower
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
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EPIP1 Epithelia # 1CatCowDogHorse
EPIP2 Epithelia # 2Guinea PigHamsterMouseRabbitRat
FETH2 Feather # 2ChickenDuckGooseTurkey
FOOD2 Food–FruitAppleBananaPeachPear
FOOD4 Food–GrainBarleyRiceRyeWheat
FOOD8 Food–Nut # 1AlmondBrazil NutCoconutHazelnutPeanut
FOOD1 Food–Nut # 2CashewPecanPistachioWalnut
FOOD6 FoodCodfishCow’s MilkEgg WhitePeanutSoybeanWheat
FDP1 Food Panel # 2CabbagePaprikaSpinachTomato
FOOD7 Food–SeafoodBlue MusselCodfishSalmonShrimpTuna
FOOD3 Food–VegetableBroccoliCarrotCornGreen PeaWhite Bean
GRAS1 Grass # 1June/Kentucky BlueMeadow FescueOrchardRyeTimothy
GRAS2 Grass # 2BahiaBermudaJohnsonJune/Kentucky BlueRyeTimothy
GRAS3 Grass # 3Cultivated RyeRyeSweet VernalTimothyVelvet Leaf
HD1 House DustCockroachDermatophagoides farinaeDermatophagoides pteronyssinusHouse Dust/H-S Lab
MOLD1 MoldAlternaria tenuisAspergillus fumigatusCandida albicans (Monilia)Cladosporium herbarumHelminthosporium halodesPenicillium chrysogenum
OCC2 Occupational # 2Isocyanate HDIIsocyanate MDIIsocyanate TDIPhthalic Anhydride
TREE1 Tree # 1BirchBox Elder/MapleElmOakWalnut
TREE2 Tree # 2CottonwoodElmMesquiteMountain CedarOak
Screening PanelsOne result per panel selected*
TREE3 Tree # 3CottonwoodElmGrey AlderHazelnutWillow
TREE4 Tree # 4AcaciaEucalyptusMelaleucaOlivePineWillow
WEED1 Weed # 1English PlantainLamb’s QuartersMugwortRussian ThistleShort Ragweed
WEED2 Weed # 2English PlantainLamb’s QuartersMugwortScaleWestern Ragweed
WEED3 Weed # 3English PlantainLamb’s QuartersRed SorrelRussian Thistle
WEED4 Weed # 4Giant RagweedShort RagweedWestern Ragweed
*A pooled reagent is used to obtain 1 screening result per panel.
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
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DAGR Dairy and GrainEgg WhiteMilkWheatOatSoybean
NEREG Northeast RegionalOakTimothy GrassJune GrassShort RagweedLambs QuartersCat EpitheliumDog DanderCladosporiumAlternaria tenuisHouse Dust Mites/Dermatophagoides farinae
NSIP Non-Seasonal InhalantCat EpitheliumDog DanderPenicillium chrysogenumCladosporiumAspergillus fumigatusAlternaria tenuisHouse Dust/Greer LabHouse Dust/H-S LabHouse Dust Mites/Dermatophagoides farinaeHouse Dust Mites/Dermatophagoides pteronyssinus
NUTSP NutsAlmondSesame SeedPeanutPecan-FoodCoconut
SEAFP SeafoodCodfishCrabShrimpTunaLobster
SEAS Seasonal InhalantsRye GrassJune GrassShort RagweedEnglish PlantainLambs QuarterBox Elder/MapleOakElmTimothy GrassSilver Birch
INSEC Stinging InsectsHoneybee VenomYellow Jacket VenomWasp VenomYellow Faced Hornet VenomWhite Faced Hornet Venom
Pediatric profilesPAS3 Pediatric Allergy Screen <3 Years
Egg WhiteMilkWheatSoybeanHouse Dust Mites/Dermatophagoides farinae
PAS38 Pediatric Allergy Screen 3 to 8 YearsEgg WhiteHouse Dust Mites/Dermatophagoides farinaeTimothy GrassShort RagweedCat EpitheliumAlternaria tenuis
PAS8 Pediatric Allergy Screen >8 YearsHouse Dust Mites/Dermatophagoides farinaeShort RagweedTimothy GrassCat EpitheliumAlternaria tenuis
RPR1Respiratory Profile, Region 1, North Atlantic (CT, MA, ME, NJ, NH, NY, PA, RI, VT)Immunoglobulin E (IgE)House Dust Mites/Dermatophagoides pteronyssinusHouse Dust Mites/Dermatophagoides farinaeCat EpitheliumDog DanderBermuda GrassTimothy GrassCockroachPenicillium chrysogenumCladosporiumAspergillus fumigatusAlternaria tenuisBox Elder/MapleSilver BirchMountain CedarOakElmWalnut TreeEastern SycamoreCottonwoodWhite AshMulberryShort RagweedMugwortRough PigweedRed Sorrel
RPR2 Respiratory Profile, Region 2, Mid-Atlantic (DC, DE, MD, NC, VA)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Johnson Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Silver Birch Mountain Cedar Oak Elm Cottonwood Pecan HickoryMulberry Short Ragweed Rough Pigweed Red Sorrel
RPR3 Respiratory Profile, Region 3, South Atlantic (GA, N.FL, SC)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Bahia Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Silver Birch Mountain Cedar Oak Elm Pecan Hickory Short Ragweed Rough Pigweed Red Sorrel Nettle
Profile TestsIndividual results are reported for each member of the profile
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
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RPR4Respiratory Profile, Region 4, Subtropic Florida (Florida S. of Orlando)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Bahia Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Mountain Cedar Oak Elm Australian Pine Short Ragweed Rough Pigweed Red Sorrel Nettle Blomia tropicalis
RPR5Respiratory Profile, Region 5, Ohio Valley (IN, KY, OH, TN, WV)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Silver Birch Mountain Cedar Oak Elm Walnut Tree Eastern Sycamore Cottonwood White Ash Pecan Hickory Mulberry Short Ragweed Russian Thistle Rough Pigweed Red Sorrel
RPR6Respiratory Profile, Region 6, South Central (AL, AR, LA, MS)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Silver Birch Mountain Cedar Oak Elm Walnut Tree Pecan Hickory Mulberry Short Ragweed Rough Pigweed Rough Marsh Elder
RPR7Respiratory Profile, Region 7, Northern Midwest (MI, MN, WI)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Silver Birch Mountain Cedar Oak Elm Cottonwood White Ash Mulberry Short Ragweed Russian Thistle Rough Marsh Elder Nettle
RPR8Respiratory Profile, Region 8, Central Midwest (IA, IL, MO)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Mountain Cedar Oak Elm Walnut Tree Eastern Sycamore Cottonwood White Ash Pecan Hickory Mulberry Short Ragweed Russian Thistle Rough Pigweed Rough Marsh Elder
RPR9Respiratory Profile, Region 9, Great Plains (KS, ND, NE, SD)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Mountain Cedar Oak Elm Cottonwood White Ash Mulberry Short Ragweed Russian Thistle Red Sorrel Nettle
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
MC0767-08rev0618
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RPR10Respiratory Profile, Region 10, Southwestern Grasslands (OK, TX)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Silver Birch Mountain Cedar Oak Elm Cottonwood White Ash Pecan Hickory Mulberry Short Ragweed Rough Pigweed Rough Marsh Elder Red Sorrel Nettle
RPR11Respiratory Profile, Region 11, Rocky Mountain (AZ [Mt], CO, ID [Mt], NM, UT [Mt], WY)Immunoglobulin E (IgE)House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Grey Alder Mountain Cedar Oak Elm Olive Tree Cottonwood Mulberry Short Ragweed Mugwort Russian Thistle Rough Pigweed Red Sorrel
RPR12Respiratory Profile, Region 12, Arid Southwest (Southern AZ Desert, Southern CA Desert)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Rye Grass Johnson Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Olive Tree Mountain Cedar Oak Elm Cottonwood Acacia Short Ragweed Mugwort Rough Pigweed Russian Thistle
RPR13Respiratory Profile, Region 13, Southern Coastal CaliforniaImmunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy GrassJohnson Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Olive Tree Grey Alder Mountain Cedar Oak Elm Walnut Tree Cottonwood Mulberry Short Ragweed Mugwort Russian Thistle Rough Pigweed
RPR14Respiratory Profile, Region 14, Central CaliforniaImmunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy GrassCockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Olive TreeGrey AlderMountain CedarOak Elm Eastern SycamoreSilver BirchMulberryShort RagweedMugwortRussian Thistle Rough Pigweed
RPR15Respiratory Profile, Region 15, Intermountain West (Southern ID, NV)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Olive Tree Box Elder/Maple Mountain Cedar Oak Elm Cottonwood Mulberry Short Ragweed Mugwort Russian Thistle Rough Pigweed
Patient ID (Medical Record Number) Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy) Client ID Client Order No.
Patient Information (required)
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RPR16Respiratory Profile, Region 16, Inland Northwest (OR, Central and Eastern WA)Immunoglobulin E (IgE) House Dust Mites/ Dermatophagoides pteronyssinus House Dust Mites/ Dermatophagoides farinae Cat Epithelium Dog Dander Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Grey Alder Mountain Cedar Oak Elm Box Elder/Maple Cottonwood Silver Birch Red Sorrel Mugwort Russian Thistle Rough Pigweed
RPR17Respiratory Profile, Region 17, Pacific Northwest (Northwestern CA, Western OR, WA)Immunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Box Elder/Maple Grey Alder Silver Birch Mountain Cedar Oak Elm Walnut Tree Cottonwood White Ash Short Ragweed Red Sorrel Nettle Rough Pigweed
RPR18Respiratory Profile, Region 18, AlaskaImmunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Timothy Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Grey Alder Silver Birch CottonwoodMugwort Red Sorrel
RPR19Respiratory Profile, Region 19, Puerto RicoImmunoglobulin E (IgE) House Dust Mites/Dermatophagoides pteronyssinus House Dust Mites/Dermatophagoides farinae Cat Epithelium Dog Dander Bermuda Grass Red Top Johnson Grass Cockroach Penicillium chrysogenum Cladosporium Aspergillus fumigatus Alternaria tenuis Aureobasidium pullulans Oak Elm Eucalyptus Red Sorrel Parietaria officinalis Rough Pigweed Australian Pine Blomia tropicalis
