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. Chromosomal Microarray, Blood   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chromosomal Microarray, Blood
CPT Code: 81229

Specimen Type: Blood

Tube Type/Collection Container: Purple (EDTA) tube AND Green (Sodium heparin) tubes; Whole Blood

Collection Volume: 3.0 mL purple(EDTA) and 4.0 mL green(Sodium Heparin)

Storage: Purple (EDTA) refrigerated; Green (Sodium Heparin) ambient

Availability: Sent to Reference Laboratory

Special Instructions: Must collect both purple (EDTA) and green (sodium heparin) tubes; Requires completed Reference Lab paperwork.

TAT: 8-21 days


Lab/Phone: 330-543-8418

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: