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. Methemoglobin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Methemoglobin
CPT Code: 83050

Specimen Type: Blood

Tube Type/Collection Container: Heparinized syringe, Green top (lithium heparin) microtainer

Collection Volume: 0.5 mL microtainer or syringe; (2) 180 uL capillary tubes

Cause for rejection: Clotted, specimen not sent on ice, air bubbles

Storage: On ice

Availability: Daily, 24 hours; STAT

Methodology: Spectrophotometric measurement

Special Instructions: Place specimen on ice and deliver to lab immediately.

TAT: 30 minutes


Lab/Phone: 330-746-9623

Additional Info: Reference range: 0.4 - 1.1 % THgb

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: