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. NATP Workup   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for NATP Workup
CPT Code: 86022

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood & Red top (no anticoagulant) tube (Do NOT use Serum Separator Tubes)

Collection Volume: 14.0 mL EDTA & 7.0 mL serum

Storage: Ambient

Availability: Sent to reference lab

Methodology: Platelet Antibody Screen, Platelet Associated IgG, HPA-1a (PLA1) Typing

Special Instructions: Test should be ordered under the baby's Medical Record Number: Collection: Mother: 1-7 mL serum, 14 mL EDTA whole blood Father: 14 mL EDTA whole blood baby: no specimen required Laboratory will notify Red Cross. Specimens can only be sent Mon-Thur unless special arrangements have been made. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 2 weeks


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: