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. Phenylalanine and Tyrosine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Phenylalanine and Tyrosine
CPT Code: 8403084510

Specimen Type: Blood

Tube Type/Collection Container: Blood Spot Card only

Collection Volume: Filter paper must be saturated

Cause for rejection: Blood Spot card where filter paper is not saturated with blood. DO NOT USE STATE SCREEN CARD

Storage: Ambient

Availability: Sent to Reference Laboratory

Special Instructions: Do not allow capillary tube or patient heel to touch the collection card. Allow sample to air dry for 3 hours before sending to laboratory. Filter paper on Blood Spot card must be saturated with blood.

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Phenylalanine: 0.7-3.0 mg/dL Tyrosine: 0-30 days: 42-99 umolL 1month-15years: 29-86 umol/L >16years: 21-87 umol/L

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: