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. Lymphocyte Proliferation, Mitogens   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Lymphocyte Proliferation, Mitogens
CPT Code: 86353

Specimen Type: Whole Blood

Tube Type/Collection Container: Green top (Sodium Heparin) tube

Collection Volume: <3 mos: 1.0 mL 3 mos-5 years: 2.0 mL 6-18 years: 3.0 ml >18 years: 10.0 mL

Storage: Ambient

Availability: Sent to Reference Laboratory

Methodology: Flow Cytometry

Special Instructions: Specimens must arrive within 24 hours of draw and by 10:00 a.m. on Friday. Send specimens Sunday through Thursday only.

TAT: 3-11 days


Lab/Phone: 330-543-8417

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: