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. Cytospin Preparation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cytospin Preparation
CPT Code: 85999

Specimen Type: Body fluid

Tube Type/Collection Container: Fluid container

Collection Volume: 1.0 mL

Cause for rejection: Specimens more than 1 hour old, specimens grossly clotted

Storage: Ambient

Availability: Daily, 24 hours

Methodology: Forcefully spun cellular sediments to microscope slide

Special Instructions: Specify body fluid type. Two or four cytospin preps will be prepared and sent to pathology for evaluation.

TAT: 1 hour


Lab/Phone: 330-746-9623

Additional Info: Reference range: Done

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: