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. Cystine, Pl Univ of California   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cystine, Pl Univ of California
CPT Code: 84999, 82131

Specimen Type: Blood

Tube Type/Collection Container: Yellow Top (ACD Solution A) tube: Whole Blood

Collection Volume: 5.0 mL (minimum 2.5 mL)

Cause for rejection: Yellow top with ACD Solution B is NOT acceptable.

Storage: Refrigerate within 1 hour of collection

Availability: Sent to reference lab

Methodology: Intracellular Cystine Assay

Special Instructions: Special tube required. Do not Freeze. Collect and ship specimens Monday-Thursday by FedEx Priority Overnight on the same day the sample is collected. Indicate Date and Time of last medication dose.

TAT: 10 days


Lab/Phone: 330-543-8418

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: