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. Cordstat Drug Screen   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cordstat Drug Screen
CPT Code: 80101x13 80100X1

Specimen Type: Umbilical cord tissue

Tube Type/Collection Container: Kit provided by USDTL Laboratory for specimen and requisition

Collection Volume: 6 inches umbilical cord tissue

Cause for rejection: Umbilical cord rinsed with alcohol or fixed with formalin

Storage: Ambient

Availability: Sent to Reference Laboratory

Special Instructions: Sample size is 6 inches of umbilical cord tissue that has been drained, exterior rinsed with saline (NO alcohol product),  and patted dry. Umbilical cord is NOT fixed in formalin.

TAT: 2-3 days


Additional Info: Umbilical cord is stored at room temperature for 7days, can be refrigerated (2-8 degrees C) for up to 3 weeks and frozen (<10 degrees C) up to 1 year.

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: