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. Leukocyte Alkaline Phosphatase   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Leukocyte Alkaline Phosphatase
CPT Code: 85540

Specimen Type: Whole Blood

Tube Type/Collection Container: Green top (sodium or lithium heparin) tube: Whole Blood

Collection Volume: 5.0 mL

Storage: Ambient

Availability: Sent to Reference Laboratory (ARUP)

Methodology: Stain

Special Instructions: Please order ZMSO with comment LAP to ARUP Collect between 1000 and 1400 Monday through Thursday and send to the lab immediately. Test will not be performed if neutrophil count is < 1000/ul or specimen is collected in EDTA.

TAT: 1 day


Lab/Phone: 330-543-8418

Additional Info: Reference Range: Leukocyte Alkaline Phosphatase: Female 33-149 (no units) Male 22-124 (no units)

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: