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)

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: