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. Protein Electrophoresis, Serum   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Protein Electrophoresis, Serum
CPT Code: 84165, 84155

Specimen Type: Blood

Tube Type/Collection Container: Red top( no anticoagulant)

Collection Volume: 2.5 mL (minimum 1.25 mL)

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Total Protein - Biuret Protein Electrophoresis - Agarose Gel Electrophoresis Immunofixation- Immunofixation and or / Immunodiffusion

TAT: 1-2 days

Panel Includes: Total Protein, Albumin, Alpha -1 globulin, Alpha -2 globulin, Beta globulin, Gamma globulin, A/G Ratio, M spike, Impression


Lab/Phone: 330-543-8418

Additional Info: Reference range: Total Protein > or = 1 year: 6.3-7.9 g/dL Albumin: 3.4-4.7 g/dL Alpha-1-globulin: 0.1-0.3 g/dL Alpha-2-globulin: 0.6-1.0 g/dL Beta globulin: 0.7-1.2 g/dL Gamma globulin: 0.6-1.6 g/dL

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: