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. Zinc   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Zinc
CPT Code: 84630

Specimen Type: Blood

Tube Type/Collection Container: Dark blue (trace metal) tube

Collection Volume: 7.0 mL (minimum 3.0 mL)

Storage: Refrigerated

Availability: Mon-Fri (0800-1600); STAT

Methodology: Atomic Absorption Spectrophotometry

Special Instructions: To prevent contamination of the specimen, the stopper should not be removed when filling tube with blood. If using a syringe, transfer the blood directly into the tube, without removing the top, using a blood transfer device.

TAT: 4 hours


Lab/Phone: 330-543-8484

Additional Info: Reference range: 77-137 ug/dL

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: