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. Erythroblastosis Evaluation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Erythroblastosis Evaluation
CPT Code: 86900

Specimen Type: Blood

Tube Type/Collection Container: Red top glass (no anticoagulant) tube

Collection Volume: 4.0 mL serum from mother and 0.3 mL from patient

Cause for rejection: Improperly labeled specimen, gross hemolysis

Storage: Refrigerated

Availability: Daily (0730-1630)

Methodology: Tube Testing

Special Instructions: 7.0 mL red top tube required from mother of patient. All Blood Bank specimens must be accompanied by a completely filled out Blood Bank Requisition to include two signatures at the time of specimen collection. Mislabeled Blood Bank Specimens will not be processed, regardless of the situation. Specimens for Blood Bank testing with any type of mismatched or missing information must be redrawn.

TAT: 1.5 hours


Lab/Phone: 330-543-8723

Additional Info: -

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: