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. Arylsulfatase A, Leukocytes   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Arylsulfatase A, Leukocytes
CPT Code: 82657

Specimen Type: Blood

Tube Type/Collection Container: Yellow top (ACD) tube: Whole Blood

Collection Volume: 7.0 m (5.0 mL minimum)

Cause for rejection: If blood is transferred to another container specimen will be rejected.

Storage: Refrigerated

Availability: Sent to reference lab.

Methodology: Colorimetric Enzyme Assay

Special Instructions: Specimen must arrive within 48 hours of draw to be stabilized. Draw specimen Monday through Thursday only and not the day before a holiday. Specimen should be drawn and packaged as close to shipping time as possible. Do not transfer blood to other containers.

TAT: 3-5 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: > or =62 nmol/h/mg

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: