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 (minimum 1.8 mL) Must use appropriate sodium citrate tube based on volume of blood drawn (1.8 mL or 2.7 mL tube)

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: To determine Von Willebrands disease, other recommended testing includes: Factor VIII, Ristocetin Cofactor, APTT

TAT: 2 weeks


Lab/Phone: 330-543-8416

Additional Info: Reference range: Normal: 50-160%

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: