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. Aluminum, Serum   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Aluminum, Serum
CPT Code: 82108

Specimen Type: Blood

Tube Type/Collection Container: Navy Blue top (trace metal) tube

Collection Volume: 3.0 mL (minimum 1.0 mL)

Cause for rejection: Hemolysis will interfere with results.

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Dynamic Reaction Cell-Inductively Coupled Plasma-Mass Spectrometry (DRC-ICP-MS)

Special Instructions: Separate serum from cells ASAP. Carefully clean skin prior to collection with alcohol swab. Use powderless gloves.

TAT: 1-5 days


Lab/Phone: 330-543-8418

Additional Info: Reference Values: 0-6 ng/mL; <60 ng/mL (dialysis patients)

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: