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. Nitroblue Tetrazolium Test   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Nitroblue Tetrazolium Test
CPT Code: 86384

Specimen Type: Blood

Tube Type/Collection Container: None

Collection Volume: 4 coverslip preps (1.0 mL minimum)

Cause for rejection: Preps which have dried; preps in which specimen is not contained within the endotoxin circle

Storage: Refrigerated

Availability: Fri (0900-1000)

Methodology: Microscopic Evaluation of Dye reduction by endotoxin stimulated neutrophils

Special Instructions: Specimen cannot be stored. Blood must be collected without anticoagulants on specially prepared slides. Test must be scheduled with the Centralized Core Lab (CCL-330-543-8416), Akron campus only, in advance. Call CCL technologist when patient arrives for testing. Inform laboratory of any additional test to be drawn at this time.

TAT: 24 hours


Lab/Phone: 330-543-8416

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 Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

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


Physician Signature: Date: