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. Somatostatin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Somatostatin
CPT Code: 84307

Specimen Type: Blood

Tube Type/Collection Container: Mayo Misc. Tube

Collection Volume: 10.0 mL (minimum 3.0 mL)

Storage: Frozen

Availability: Sent to reference lab

Methodology: Direct Radioimmunoassay (RIA)

Special Instructions: Collect 10.0 mL of blood in special tube containing G.I Preservative (Mayo Supply number T125). Specimen should be separated and 3.0 mL plasma frozen as soon as possible. 1. Patient should be fasting 10-12 hours prior to collection. 2. Patient should not be on any antacid medication or medications that affect insulin secretion or intestinal motility, if possible, for at least 48 hours prior to collection. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 5-7 days


Lab/Phone: 330-543-8418

Additional Info: Reference range available on 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: