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. Galactose 1 Phosphate   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Galactose 1 Phosphate
CPT Code: 84378

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium heparin) tube: Whole Blood

Collection Volume: 4.0 mL (minimum 2.0 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Ultraviolet, Enzymatic

Special Instructions: Draw blood in a green-top(heparin) tube(s), and process a minimum of 2 mL of heparinized whole blood as follows: 1. Immediately centrifuge for 10 minutes at 2,000 rpm. 2. Discard the plasma and buffy coat layers. 3. Add a cold 0.9% saline solution to the erythrocytes (about 2 times the volume of erythrocytes). 4. Mix gently by inversion and centrifuge again for 10 minutes at 2,000 rpm. 5. Remove and discard the saline. 6. Repeat the wash steps (3-5) 2 more times. 7. After the final centrifugation, remove and discard the saline and a thin layer of the top cells. 8. Immediately freeze the washed, packed cells (red cell pellet from step 7) and send specimen frozen in plastic vial.

TAT: 7 days


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

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: