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. Hemoglobin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hemoglobin
CPT Code: 85018

Specimen Type: Blood

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

Collection Volume: 2.0 mL (minimum 0.3 mL)

Cause for rejection: Specimen hemolyzed, clotted, diluted with IV fluid; held at RT for more than 8 hours or at 4C for more than 24 hours

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Flow Cell Spectrophotometry

Special Instructions: Lipemic plasma or white count > 50,000/mm3 may falsely elevate the hemoglobin.

TAT: 4 hours


Lab/Phone: 330-543-8416

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: