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. Occult Blood, Qual   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Occult Blood, Qual
CPT Code: 82272

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: 1 gram stool specimen

Storage: Ambient

Availability: Daily, 24 hours; STAT

Methodology: Guaiac

Special Instructions: Patient should follow a diet free of red meats, vitamin C, ascorbic acid, turnips, horseradish, melons, aspirin, and anti-inflamatory drugs for 7 days prior to testing and for the duration of testing.

TAT: 1 hour


Lab/Phone: 330-746-9623

Additional Info: Reference range: Normal = Negative

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: