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. CK, Total and CKMB   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for CK, Total and CKMB
CPT Code: 82550, 82553

Specimen Type: Blood

Tube Type/Collection Container: Gold Top SST (Serum Separator tube, no anticoagulant)

Collection Volume: 1.5mL (minimum 0.75mL)

Cause for rejection: Hemolysis

Storage: Refrigerated

Availability: Sent to reference lab

TAT: 2 hours


Lab/Phone: 330-746-9623

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: