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. AFP, Amniotic Fluid   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for AFP, Amniotic Fluid
CPT Code: 82106

Specimen Type: Amniotic fluid

Tube Type/Collection Container: Fluid container

Collection Volume: 0.5 mL (minimum 300 uL)

Cause for rejection: Gestational age < 14 weeks or > 25 weeks

Storage: Refrigerated

Availability: Mon-Fri

Methodology: Chemiluminescence Assay

Special Instructions: Specimen must be in lab by 0730 for same day results.

TAT: 8 hours


Lab/Phone: 330-543-8484

Additional Info: Reference range: < = 2.0 MOM

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: