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. von Willebrand Antigen   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for von Willebrand Antigen
CPT Code: 85244

Specimen Type: Blood

Tube Type/Collection Container: Blue top (sodium citrate) tube

Collection Volume: 2.7 mL

Cause for rejection: Sample hemolyzed, clotted, diluted with IV fluid; contaminated with heparin; improperly filled; not kept on ice; received > 1 hour after drawn

Storage: Frozen

Availability: Mon-Fri (0700-1400)

Methodology: Electroimmunodiffusion Assay (EIA)

Special Instructions: A Factor VIII Coagulant Activity and a PTT determination should be performed in conjunction with this test in order to aid with the interpretation of test results.

TAT: 2 weeks


Lab/Phone: 330-543-8416

Additional Info: Reference range: 0-1 day: 36-315% 2-5 days: 50-279% 6-30 days: 19-270% 1-3 months: 57-226% 4-11 months: 32-216% 1-5 years: 60-132% 6-10 years: 44-158% 11-16 years: 46-168% Adult: 50-173%

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: