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. Hereditary Hemochromatosis DNA Test   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hereditary Hemochromatosis DNA Test
CPT Code: 81256

Specimen Type: Blood

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

Collection Volume: 2.5 mL (minimum 0.5 mL)

Storage: Ambient

Availability: Sent to Reference Laboratory

Methodology: Polymerase Chain Reaction (PCR)-based assay (using LightCycler tech.) used to test for 3 mutations in the HFE gene: C282Y,H63D,S65C

Special Instructions: Requires "Informed Consent for Genetic Testing" Requires Mayo lab "Congenital Inherited Diseases Patient Information" Sheet. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 5-14 days


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 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: