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. Alpha -1-Antitrypsin, Stool (Mayo)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Alpha -1-Antitrypsin, Stool (Mayo)
CPT Code: 82103

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: Random stool collection (minimum 5 grams)

Storage: Frozen

Availability: Sent to reference lab

Methodology: Nephlometry

TAT: 3 days


Lab/Phone: 330-543-8418

Additional Info: Send frozen in containers supplied. This test is for RANDOM samples ONLY. For 24hr collections please order on a manual requisition and also send 1mL serum (SST tube).

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: