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. Homocysteine, Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Homocysteine, Urine
CPT Code: 83090

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 2.0 mL random urine

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) Stable Isotope Dilution Analysis

Special Instructions: Have patient fast overnight and discard first morning urine specimen. Have patient continue to fast and collect next random specimen. Place on ice and deliver to lab promptly.

TAT: 2 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 0-9 umol/gram of creatinine

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: