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. Stickler Syndrome Type I & II   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Stickler Syndrome Type I & II
CPT Code: 81479 X2

Specimen Type: Whole Blood

Tube Type/Collection Container: Purple top (EDTA) tube

Collection Volume: 5.0 mL (minimum 4.0 mL)

Storage: Ambient

Availability: Sent to Reference Laboratory

Methodology: DNA Sequencing

Special Instructions: Requires Informed Consent for Genetic Testing.

TAT: 3-4 weeks


Lab/Phone: 330-543-8418

Additional Info: Whole blood should be refrigerated until shipped. All samples can be shipped at ambient temperature via an overnight courier.

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: