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. IBD sgi Diagnostic   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for IBD sgi Diagnostic
Specimen Type: Blood

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

Collection Volume: 4.0 mL - red top; 2.0 mL- lavender

Cause for rejection: QNS

Storage: Refrigerate

Availability: Sent to Reference Laboratory

Special Instructions: This gets sent to Prometheus.

Panel Includes: ASCA IgA ELISA, ASCA IgG ELISA, Anti-OmpC IgA ELISA, Anti-CBir1 IgG ELISA, Anti-A4-Fla2 IgG ELISA, Anti-FlaX IgG ELISA, IBD-specific pANCA, AutoAntibody ELISA, IF A Perinuclear Pattern, DNAse Sensitivity, ATG16L1 (SNP (rs2241880), ECM1 (SNP (rs3737240), NKX2-3 (SNP (rs10883365 ), STAT3 (SNP (rs744166), ICAM-1, VCAM-1, VEGF, CRP, SAA


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: