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.

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: