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. Iontophoresis   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Iontophoresis
CPT Code: 89360

Specimen Type: Sweat

Tube Type/Collection Container: Specimen container

Collection Volume: 0.03 mL (minimum 0.01 mL)

Cause for rejection: Insufficient sample for testing

Storage: Ambient

Availability: Sun-Fri (0900-1100)

Methodology: Pilocarpine

Special Instructions: Outpatients must be scheduled in advance. Patient must be out of a mist tent and preferably without an IV. Iontophoresis is to be performed by trained lab personnel only. For Outpatients, test should only be drawn in outpatient lab. Testing is performed on the Akron campus only.

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Reference range is not applicable

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: