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. Chloride, Misc Fluid   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chloride, Misc Fluid
CPT Code: 82438

Specimen Type: Any fresh body fluid (pleural, synovial, drainages, etc)

Tube Type/Collection Container: Fluid container

Collection Volume: 0.3 mL

Cause for rejection: -

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Ion selective electrode indirect

Special Instructions: Please specify type of fluid. Deliver to lab immediately.

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Reference range: Not Established; Dr. interpretation only

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: