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. Cold Agglutinin Titer   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cold Agglutinin Titer
CPT Code: 86156 (screen), 86157 (titer if appropriate)

Specimen Type: Blood

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

Collection Volume: 10.0 mL (minimum 2.5 mL)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Titration-Red Cell Agglutination at 4 degrees C

Special Instructions: Do not refrigerate prior to separation of serum from red cells.

TAT: 1-3 days


Additional Info: Reference Values: Screen: Negative Titer: <1:64 If screen is positive, titer results will be reported.

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: