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. Long Chain Fatty Acids   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Long Chain Fatty Acids
CPT Code: 82726

Specimen Type: Blood-Plasma

Tube Type/Collection Container: Purple top (EDTA) tube

Collection Volume: 2.0 mL plasma (minimum 1.0 mL)

Cause for rejection: -

Storage: Ambient

Availability: Sent to reference lab

Methodology: Capillary Gas Chromatography/Mass Spectrophotometry

Special Instructions: -

TAT: 8-12 days

Panel Includes: C26:0, C26:1, Phytanic Acid, Pristanic Acid, C22:0, C24:0, C22:1w9, C24/22, C26/C22


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

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: