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. Complement AH50   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Complement AH50
CPT Code: 86161

Specimen Type: Blood

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

Collection Volume: 2.5 mL (minimum 0.5 mL)

Storage: Frozen

Availability: Sent to Reference Laboratory

Methodology: Enzyme-Linked Immunosorbent Assay (ELISA).

Special Instructions: Immediately after drawing the specimen, place the tube on wet ice. Spin down and separate serum from clot Immediately freeze specimen. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 2-7 days


Lab/Phone: 330-543-8418

Additional Info: Reference Values: > or = 46% normal

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: