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. Direct Antiglobulin Test   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Direct Antiglobulin Test
CPT Code: 86880

Specimen Type: Blood

Tube Type/Collection Container: Lavender (EDTA)tube

Collection Volume: <4 months: 2 lavender (EDTA) microtainers; 4 months-6years: 1, 6mL lavender (EDTA)tube (5mL minimum); >6 years: 2, 6mL lavender (EDTA) tube; sickle patient: 2-3, 6 mL lavender (EDTA) tubes

Cause for rejection: Improperly labeled specimen, gross hemolysis

Storage: Refrigerated

Availability: Daily, 24 hours

Methodology: Tube Testing

Special Instructions: All Blood Bank specimens must be accompanied by a completely filled out Blood Bank Requisition to include two signatures at the time of specimen collection. Mislabeled Blood Bank Specimens will not be processed, regardless of the situation. Specimens for Blood Bank testing with any type of mismatched or missing information must be redrawn.


Lab/Phone: 330-746-9623

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: