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. Hepatitis B Viral DNA, Ultra Quant   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hepatitis B Viral DNA, Ultra Quant
CPT Code: 87517

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (Serum Separator) tube

Collection Volume: 4.0 mL (minimum 2.0mL)

Storage: Frozen

Availability: Sent to reference lab.

Methodology: Real-Time Polymerase Chain Reaction (PCR)

Special Instructions: Spin down within 6 hours of draw. Freeze specimen within 48 hours of draw

TAT: 2-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Undetected

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: