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. Anti-Thrombin III Activity   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Anti-Thrombin III Activity
CPT Code: 85300

Specimen Type: Blood

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

Collection Volume: 2.7mL (minimum 1.8 mL)

Cause for rejection: Specimens which have visible hemolysis, are clotted, collected in the wrong tube, diluted with IV fluids, contamination with heparin, tubes that are over or under filled, specimens not kept on ice, or specimens received more than one hour post collection.

Storage: Frozen

Availability: Daily, 0700-1500

Methodology: Chromogenic Assay, BCSXP

Special Instructions: Specimens should be spun down & platelet poor plasma frozen if coming from an outside facility (plasma volume minimum 0.5 mL).

TAT: 4 hours


Lab/Phone: 330-543-8418

Additional Info: Reference range: 1 day - 3 month: 39-87% > 3 month: 88-135%

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: