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. Ambien   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Ambien
CPT Code: 80368

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) or Green top (sodium heparin) tube

Collection Volume: 5.0 mL (minimum 1.0 mL)

Storage: Refrigerated

Availability: Sent to reference lab

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

TAT: 3-5 days


Lab/Phone: 330-543-8377

Additional Info: Therapeutic 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: