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. Reticulin IgA/G Abs   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Reticulin IgA/G Abs
CPT Code: 86255 (86256 if titer)

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 1.5 mL (minimum 0.5 mL)

Cause for rejection: grossly hemolyzed or grossly lipemic

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Indirect Immunofluorescence Assay (IFA)

Special Instructions: Days Performed: Mon-Sun

TAT: 3-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative NOTE: If positive, results will be tittered at no additional charge.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: