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. Oxalate, Plasma   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Oxalate, Plasma
CPT Code: 83945

Specimen Type: Blood

Tube Type/Collection Container: Green top (sodium heparin)

Collection Volume: 10mL (minimum 5.0mL)

Cause for rejection: Non- heparinized specimen

Storage: Frozen

Availability: Sent to reference lab; Mon-Fri

Methodology: Spectrometry

Special Instructions: Fasting 12 hours is recommended. Patient should avoid taking vitamin C supplements for 24 hours prior to draw. Place on wet ice immediately. Centrifuge within 1 hour of the draw and freeze. Reference lab will adjust the pH of the specimen.

TAT: 3-7 days


Lab/Phone: 330-543-8418

Additional Info: Reference range <1.8mcmol/L

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: