Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


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. Porphyrins Screen, Urine Random   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Porphyrins Screen, Urine Random
CPT Code: 84119, 84106

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: First morning void of urine

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Spectrophotometric/Watson-Schwartz

Special Instructions: 10.0 mL (minimum 3.0 mL) aliquot from a well-mixed first morning void of urine. Protect the specimen from light.

TAT: 2-3 days

Panel Includes: Porphobilinogen Screen, Porphyrin Screen


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: