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: 50.0 (minimum 25.0 mL) from a 24hr collection

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: PTU/8261: Dye Binding (Pyrogallol Red)

Special Instructions: Collect a 24-hour urine specimen, no preservative. 24-Hour volume is required.

TAT: 2 -3 days

Panel Includes: Urine Total Protein, % Albumin, % Alpha 1 globulin, % Alpha 2 globulin, % Beta globulin, % Gamma globulin, A/G Ratio, M spike, Impression


Lab/Phone: 330-543-8418

Additional Info: Reference range: Protein, Total: <102 mg/24 hours If protein concentration is abnormal, the following fractions, if present, will be reported as a percent of the protein, total. Albumin Alpha-1-globulin Alpha-2-globulin Beta-globulin Gamma-globulin

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: