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. Chromosome Analysis, Bone Marrow, Neoplastic Disorder   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chromosome Analysis, Bone Marrow, Neoplastic Disorder
CPT Code: 88237, 88262, 88280, 88291

Specimen Type: Bone Marrow

Tube Type/Collection Container: Green top (sodium heparin) tube or bone marrow transfer solution

Collection Volume: 3.0 mL (minimum 0.5 mL)

Cause for rejection: Clotted, non-sterile, or frozen specimen

Storage: Ambient

Availability: Mon-Fri (0700-1600) Sat (0900-1300)

Methodology: Chromosome harvest of mitotic cells (with and without culturing) with G-banding

Special Instructions: Include pertinent medical findings on the requisition with suspected diagnosis and/or indication(s) for the testing.

TAT: 2-28 days


Lab/Phone: 330-543-8483

Additional Info: Interpretation is provided with report. Follow-up studies recommended as appropriate.

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: