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. Dilute RVVT   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Dilute RVVT
CPT Code: 85613 (x2)

Specimen Type: plasma

Tube Type/Collection Container: Sodium citrate (Blue) tube

Collection Volume: Two 1mL aliquots

Storage: Frozen

Special Instructions: Indicate if patient is receiving heparin or coumadin.

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference ranges: DRVVT Screen: Range: 34.7-46.9 sec DRVVT 1:1 Mix: Range: 34.7-46.9 sec DRVVT Confirm Ratio: Range: 0.99-1.20 Days Performed: Mon-Fri

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: