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. Heavy Metal Evaluation, Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Heavy Metal Evaluation, Urine
CPT Code: 82175, 83655, 83825

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 24 hour urine collection

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Inductively Coupled Plasma/Mass Spectrometry (ICP/MS)

Special Instructions: 10.0 mL aliquot from a 24 hour urine collection. Collect without preservative. Instruct patient on 24 hour urine collection. To begin the urine collection, have the patient void. DISCARD THIS URINE SPECIMEN. This is best done with the first morning specimen. Note the time and record on the requisition. From then on collect all the urine that is voided and place in container. If more than one container is needed, please mark the first as #1 of 2 and retain on the floor until the collection is complete. The final void should be made 24 hours after the first void described earlier. The specimen should be included with the collection. Refrigerate during collection. Include total volume on requisition.

TAT: 1-2 days

Panel Includes: Arsenic Urine, Lead Urine, Cadmium Urine, Mercury Urine


Lab/Phone: 330-543-8418

Additional Info: Please order as a Miscellaneous Test or send requests on a manual requisition. Reference range: Arsenic: 0-35 mcg/specimen Lead: 0-4 mcg/specimen Cadmium: 0-15 years: not established > or = 16 years: 0.0-1.3 mcg/specimen Mercury: 0-15 years: not established > or = 16 years: 0-9 mcg/specimen Toxic concentration: >50mcg/specimen The concentration at which toxicity is expressed is widely variable between patients. 50 mcg/specimen is the lowest concentration at which toxicity is usually apparent.

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: