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. Protein Electrophoresis, Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Protein Electrophoresis, Urine
CPT Code: 84166, 84156

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 10.0 (minimum 5.0 mL) random urine

Cause for rejection: Urine collected in acid container

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Electrophoresis

Special Instructions: 10.0 mL (minimum 5.0 mL) urine from a well-mixed random urine specimen. First morning void is preferred.

TAT: 2 days

Panel Includes: Urine Total Protein, % Albumin, % Alpha 1 globulin, % Alpha 2 globulin, % Beta globulin, % Gamma globulin, Interpretation


Lab/Phone: 330-543-8418

Additional Info: Reference range: No evidence of M-spike

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: