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. Peroxisomal Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Peroxisomal Panel
CPT Code: 82726X1

Specimen Type: Blood

Tube Type/Collection Container: Gold top (SST) tube

Collection Volume: 1.5 mL (minimum 0.5 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Gas Chromatography/Mass Spectrometry (GC/MS), Stable Isotope Dilution

Special Instructions: Patient preparation: 12-14 hour fast and 24 hour abstinence from alcohol. Indicate treatment, family history, and tentative diagnosis on request form. Centrifuge, separate, and freeze within 45 minutes from collection.

TAT: 4-9 days

Panel Includes: C22:0, C24:0, C26:0, C24:0/C22:0 Ratio, C26:0/C22:0 Ratio, Pristanic Acid, Phytaric Acid, Pristanic/Phytanic Ratio, Comment


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: