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. Fecal Fat, Qualitative   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fecal Fat, Qualitative
CPT Code: 82705

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: 5 grams (minimum 2 grams) random stool

Cause for rejection: Frozen

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Conventional

Special Instructions: Submit refrigerated fresh stool within 24 hours of collection. Specimen may be retrieved from bedpan if not contaminated with urine. Administration of barium, bismuth, metamucil, castor oil or mineral oil within 1 week of collection may interfere with test.

TAT: 4-5days


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 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: