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. Cryoglobulin with ID   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cryoglobulin with ID
CPT Code: 82595

Specimen Type: Blood

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

Collection Volume: 30.0 mL (minimum 6.0 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab; tested Wed

Methodology: Spectrophotometry

Special Instructions: Collect 10.0 mL from three 10.0 mL red top tubes. Do not use serum separator tubes. Immediately after collection, place tubes in 37 degree C water. Allow to clot at 37 degrees C for 90 minutes. Centrifuge and separate serum from cells. Freeze. The accuracy of this test is greatly compromised if blood is at <37 degrees during 90 minute period after collection.

TAT: 1-8 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 0-50 ug/mL

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: