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. BCR/ABL, mRNA Detection   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for BCR/ABL, mRNA Detection
Specimen Type: Whole Blood or Bone Marrow

Tube Type/Collection Container: Purple top (EDTA)tube

Collection Volume: 4.0 mL Whole Blood; 3.0 mL Bone Marrow

Cause for rejection: Specimen must arrive within 72 hours of collection

Storage: Ambient

Availability: Mon-Fri; 2 p.m.

Methodology: Reverse Transcription-Polymerase Chain Reaction (RT-PCR) with Fluorescent-Bead array Analysis

Special Instructions: The following information is required: 1. Pertinent clinical history-confirm that this test is being used for the purpose of making an initial diagnosis 2. Date of Collection 3. Specimen source (blood or bone marrow) For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly)

TAT: 5-10 days


Lab/Phone: 330-543-8418

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: