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. Factor IX Assay   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Factor IX Assay
CPT Code: 85250

Specimen Type: Blood

Tube Type/Collection Container: Blue top (sodium citrate) tube

Collection Volume: 2.7 mL (minimum 1.8 mL)

Cause for rejection: Sample hemolyzed, clotted, diluted with IV fluid; contam with heparin, improperly filled; not kept on ice; received > 1 hr after drawn

Storage: Frozen

Availability: Daily (0700-1500)

Methodology: Optical Light Scatter Detection Clotting Assay

Special Instructions: Call CCL in advance to schedule test. Indicate the time replacement therapy was administered, amount & type of therapy given, whether the specimen was drawn pre-treatment or post-treatment and the time drawn. Indicate if a specimen has been drawn from an arterial line or a line rinsed with heparin.

TAT: 4 hours


Lab/Phone: 330-543-8416

Additional Info: Reference range: 0-1 day: 17-81% 2-5 days: 17-81% 6-30 days: 24-73% 1-3 months: 24-101% 4-11 months: 42-121% 1-5 years: 55-93% 6 years-Adult: 65-145%

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: