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. Platelet Aggregation Profile   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Platelet Aggregation Profile
CPT Code: 85576

Specimen Type: Blood

Tube Type/Collection Container: Blue top (sodium citrate) tubes

Collection Volume: 25.0 mL

Cause for rejection: Specimen hemolyzed, clotted or grossly lipemic; specimen from patients who have taken drugs that inhibit platelet function; test not scheduled in advance.

Storage: Ambient

Availability: Test scheduled for weekday mornings only

Methodology: Standard Optical Aggregation in PRP (Platelet Rich Plasma)

Special Instructions: NOTE: Call Centralized Core Lab (330-543-8416) in advance to schedule. Test can be scheduled for weekday mornings at Akron campus only. Special handling is required.

TAT: 72 hours


Lab/Phone: 330-543-8416

Additional Info: Reference range is available under individual tests

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: