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. Prothrombin 20210A DNA Test   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Prothrombin 20210A DNA Test
CPT Code: 81240, 83912

Specimen Type: Whole Blood

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

Collection Volume: 2.0 mL

Cause for rejection: Specimen clotted, stored at room temperature, > 5 days old, improper anticoagulant

Storage: Refrigerated

Availability: Batch testing performed once per week

Methodology: Real-Time Polymerase Chain Reaction (PCR)

TAT: 1 week


Lab/Phone: 330-543-8722

Additional Info: Reference range: Negative for Factor II, Prothrombin 20210A mutation.

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: