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. Vitamin C   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Vitamin C
CPT Code: 82180

Specimen Type: Blood

Tube Type/Collection Container: Green top (sodium heparin) tube

Collection Volume: 2.5 mL (minimum 1.5 mL)

Cause for rejection: Hemolyzed

Storage: Frozen Critical

Availability: Sent to reference laboratory

Methodology: Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Special Instructions: Fasting specimens are preferred. Immediately place specimen on wet ice, process within 4 hours of draw Centrifuge at 4C, aliquot plasma into amber vial to protect from light

TAT: 2-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 0.6-2.0 mg/dL

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: