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. Primidone   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Primidone
CPT Code: 80184, 80188

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 2.5 mL (minimum 1.0 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Immunoassay (includes phenobarbital determination)

TAT: 1 day

Panel Includes: Primidone Phenobarbital


Lab/Phone: 330-543-8418

Additional Info: Phenobarbital (metabolite) determination is performed also for proper interpretation. Reference Values: PRIMIDONE Therapeutic concentration: Children (<5 years): 7.0-10.0 mcg/mL Adults: 9.0-12.5 mcg/mL Toxic concentration: > or = 15.0 mcg.mL PHENOBARBITAL Therapeutic concentration: Infancts and children: 15.0-30.0 mcg/mL Adults: 20.0-40.0 mcg/mL Toxic Concentration: > or = 60.0 mcg/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: