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   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Blood

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

Collection Volume: 12.5 mL (minimum 8.0mL)

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Quantitation and Qualitative Typing Precipitation at 1 Degree C.

Special Instructions: 1. Tube must remian at 37 degrees C. 2. Allow blood to clot at 37 degrees C. 3. Centrifuge at 37 degrees C. (Do not use a refrigerated centrifuge. If absolutely necessary ambient temperature is acceptable). It is very important that the specimen remian at 37 degrees C until after separation of serum from red cells. Analysis can't be performed with < 3 mL of serum

TAT: 2 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative

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: