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. Vitamin A   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Vitamin A
CPT Code: 84590

Specimen Type: Blood

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

Collection Volume: 1.25 mL (minimum 0.7 mL)

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Special Instructions: Patient preparation: 12- 14 hour fast prior to collection. Separate serum from cells immediately. Protect specimen from light

TAT: 2-5 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 0-6 years: 11.3-64.7 mcg/dL 7-12 years: 12.8-81.2 mcg/dL 13-17 years: 14.4-97.7 mcg/dL >or= 18 years: 32.5-78.0 mcg/dL

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: