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. Cardiolipin ABS   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cardiolipin ABS
CPT Code: 86147 (X3)

Specimen Type: Serum

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 1.5 mL(minimum 1.0 mL)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Enzyme Linked Immunosorbent Assay (ELISA)

TAT: 1-2 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: IgG Cardiolipin Ab: Negative: <10 GPL Borderline: 10.0-14.9 GPL Weakly Positive: 15.0-39.9 GPL Positive: 40.0-79.9 Strongly Positive: > or = 80.0 GPL IgM Cardiolipin Ab: Negative: <10 MPL Borderline: 10.0-14.9 MPL Weakly Positive: 15.0-39.9 MPL Positive: 40.0-79.9 MPL Strongly Positive: > or = 80.0 MPL IgA Cardiolipin Ab: Negative: <10.0 APL Borderline: 10.0-14.9 APL Weakly Positive: 15.0-39.9 APL Positive: 40.0-79.9 APL Strongly Positive: > or = 80.0 APL

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: