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. Ethosuximide (Mayo)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Ethosuximide (Mayo)
CPT Code: 80168

Specimen Type: Blood

Tube Type/Collection Container: Red top tube

Collection Volume: 2.5 mL (minimum 1.0mL)

Cause for rejection: Severe hemolysis, severe lipemia, severely icteric

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Enzyme-Multiplied Immunoassay Technique (EMIT)

Special Instructions: Remove serum form cells within 2 hours.

TAT: 2-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 40-100 mcg/mL Critical Value: > or equal to 101 mcg/mL Days Performed: Mon-Sun

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: