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. Carbamazepine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Carbamazepine
CPT Code: 80156

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium heparin) tube

Collection Volume: 0.4 mL

Cause for rejection: Hemolysis

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Turbidimetric Inhibition Immunoassay

Special Instructions: For therapeutic monitoring, draw peak levels approximately 12 hours post-oral ingestion and trough levels immediately prior to next dose. Consistently use same time interval for peak and trough levels and dose administration for proper serial monitoring. Please indicate whether the specimen is a peak, trough, or random level.

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Therapeutic range: 4-12 ug/mL

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: