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. Reticulocyte Count, Miller Disc   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Reticulocyte Count, Miller Disc
CPT Code: 85044

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood

Collection Volume: 2.5 mL (minimum 0.2 mL)

Cause for rejection: Specimen more than 12 hours old; specimen hemolyzed, clotted, or diluted with IV fluid

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: New methylene blue N stain with Miller disc reticle

Special Instructions: Test can also be performed on green top (heparin) tube.

TAT: 8 hours


Lab/Phone: 330-543-8416

Additional Info: Reference range: Adults 0.5%-2.0% Newborns < 5.0%

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: