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. Clomipramine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Clomipramine
CPT Code: 82492

Specimen Type: Blood

Tube Type/Collection Container: Navy Blue top (EDTA) tube

Collection Volume: 6.0 mL (minimum 3.5 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab; tested Fri

Methodology: High Performance Liquid Chromatography (HPLC)

Special Instructions: Collect immediately before next oral dose. Plasma must be taken off of the cells within 2 hours. Blood must not be allowed to remain in contact with rubber stopper.

TAT: 24 hours

Panel Includes: Clomipramine, Norclomipramine


Lab/Phone: 330-543-8418

Additional Info: Reference range: Clom 100-200 ng/dL Norclom 125-300 ng/dL

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: