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. LD, Isoenzymes   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for LD, Isoenzymes
CPT Code: 83615, 83625

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 3.0 mL (minimum 1.5 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: LD: Enzymatic, Isoenzymes: Electrophoresis

Special Instructions: Days Performed: Sun-Sat Remove serum from cells ASAP

TAT: 2-4 days

Panel Includes: Lactate Dehydrogenase, LD1, LD2, LD3, LD4, LD5


Lab/Phone: 330-543-8418

Additional Info: Reference Range: Lactate Dehydrogenase: Age: 0-30 Days; Range: 200-465 U/L Age: 1-17 Months; Range: 200-450 U/L Age: 18-24 months; Range: 165-430 U/L Age: 2-10 Years; Range: 165-430 U/L Age: 11-16 Years; Range: 127-287 U/L Age: 16-99 Years; Range: 105-230 U/L LD1: Range: 14-27% LD2: Range: 29-42% LD3: range: 16-22% LD4: Range:8-15% LD5: Range: 6-23%

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: