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: 2.5 mL (1.0 mL plasma sent to Reference Lab, frozen)

Storage: Frozen

Methodology: Clot

Special Instructions: Testing while the patient is on anticoagulant therapy, including warfarin, dabigatran, or a direct Xa inhibitor may cause a false positive result.

TAT: 1-7 days

Panel Includes: DRVVT Screen DRVVT Confirmation and ratio will be performed if the DRVVT is > or = 55.1


Lab/Phone: 330-543-8418

Additional Info: Reference ranges: DRVVT Screen Seconds: <55.1 DRVVT Confirm Seconds: No reference range provided DRVVT Ratio: <1.3

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: