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. Reducing Substances   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Reducing Substances
CPT Code: 81005

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 12.0 mL (minimum 1.0mL)

Cause for rejection: Specimen leaking from container, excessive delay in transport

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: (copper reduction) AimTab Reducing Substances Tablets, Germaine Laboratories

Special Instructions: Transport specimen to the lab within 2 hours. Stable 4 hours refrigerated.

TAT: 1 hour


Lab/Phone: 330-746-9623

Additional Info: Reference range: Normal = Negative This test was developed and its performance characteristics determined by Children's Hospital Medical Center of Akron, Laboratory. It has not been cleared or approved by the FDA. The laboratory is regulated under CLIA as qualified to perform high-complexity testing. This test is used for clinical purposes. It should not be regarded as investigational or for research.

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: