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. Oligosaccharide Screen, Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Oligosaccharide Screen, Urine
CPT Code: 84377

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 8.0 mL random urine (pediatric 2.0 mL)

Storage: Frozen

Availability: Sent to reference lab

Methodology: Matrix-Assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry

Special Instructions: Freeze Immediately

TAT: 8 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: