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. Porphyrins, Stool   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Porphyrins, Stool
CPT Code: 84126

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: 100 grams from a random stool specimen

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Spectrophotometry

Special Instructions: 100 grams random stool in a clean air-tight container. Protect from light. Sample should be kept frozen during collection. Deliver sample to the lab ASAP after collection. If the Porphyrin result is greater than 200, a Porphyrins Fractioned Stool test will be added. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 8-10 days


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: