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 7.0 mL Purple top (EDTA)tube

Collection Volume: 7.0 mL EDTA & 1.0 mL serum

Cause for rejection: -

Storage: Ambient

Availability: Sent to reference lab

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

Special Instructions: Notify Red Cross. Specimen can be refrigerated if not sent immediately.

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 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: