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 Antibody   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Platelet Antibody
CPT Code: 86022

Specimen Type: Blood

Tube Type/Collection Container: 7mL Red top (no anticoagulant)tube and 6.0 mL Purple top (EDTA)tube

Collection Volume: 6.0 mL EDTA & 7.0 mL Red top (Do not centrifuge)

Cause for rejection: SST (serum separator) tubes will be rejected.

Storage: Ambient

Availability: Sent to reference lab

Methodology: Platelet Antibody Screen, Platelet Associated IgG, HPA-1a (PLA1) Typing

Special Instructions: Must have collector (employee # and date & time) written on specimen tubes. Red Cross paperwork must be completed. Notify Red Cross. For specimens collected at Mahoning Valley: Must have collector (employee # and date & time) written on specimen tubes. Red Cross paperwork must be completed and can be obtained from Akron Campus hematology department. Store at room temperature for same day delivery; refrigerate if sent the next day.

TAT: 5 days


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

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: