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. CarboxyHgb   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for CarboxyHgb
CPT Code: 82375

Specimen Type: Blood

Tube Type/Collection Container: Heparinized syringe, Green top (lithium heparin) microtainer - no gel sepatator tubes.

Collection Volume: 0.5 mL microtainer or syringe; (2) 125 uL capillary tubes

Cause for rejection: Clotted, specimen not sent on ice, air bubbles, gel separator tubes

Storage: On ice

Availability: Daily, 24 hours; STAT

Methodology: Spectrophotometric

Special Instructions: Place specimen on ice and deliver to lab immediately. For Outpatients, test should only be drawn in outpatient locations within the Hospital on the Akron campus. If collected at an offsite location, specimen is stable only 1 hour. Call a STAT Courier.

TAT: 30 minutes


Lab/Phone: 330-543-8417

Additional Info: Reference range: Availbale 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: