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. Proinsulin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Proinsulin
CPT Code: 84206

Specimen Type: Plasma

Tube Type/Collection Container: EDTA top (lavender) tube - tube must be prechilled

Collection Volume: 1.5 mL (minimum 0.7 mL)

Cause for rejection: Specimen not drawn in a prechilled EDTA tube. Patient not fasting 12-15 hours prior to collection.

Storage: Frozen

Availability: Sent to reference lab

Methodology: Chemiluminescence Immunoassay (CLIA)

Special Instructions: Place specimen on ice after collection. Separate plasma from cells ASAP and freeze. Patient preparation 12-15 hours fast prior to collection.

TAT: 3-8 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 3-20 pmol/L

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: