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. Anti-Glomerular Basement Membrane by Western Blot   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Anti-Glomerular Basement Membrane by Western Blot
CPT Code: 8418186021

Specimen Type: Blood

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

Collection Volume: 2 mL

Cause for rejection: Specimen not sent on dry ice.

Storage: Frozen

Availability: Sent to Reference lab.

Methodology: Western Blot, ELISA

Special Instructions: Western Blot analysis performed Mon-Fri and ELISA's performed as required. Send sample on dry ice by overnight delivery (Mon-Thur). Deliveries after 6 p.m. go to Cytology refrigerator adjacent to Warren 125.

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Western Blot: Negative ELISA: > 5 ELISA EU/mL is considered positive

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: