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. Ultra-sensitive CRP   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Ultra-sensitive CRP
CPT Code: 86141

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 1.5 mL

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Immunoturbidimetric

Special Instructions: Useful for: -Assessment of risk developing myocardial infarction in patients presenting with acute coronary syndromes. -Assessment of risk of developing cardiovascular disease or ischemic events in individuals who do not manifest disease at present.

TAT: 1-2 days


Lab/Phone: 330-543-8418

Additional Info: Reference Range: Low risk: <1.0 mg/L Average risk: 1.0-3.0 mg/L High risk: >3.0 mg/L Acute inflammation: >10.0 mg/L

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: