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. Bilirubin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Bilirubin
CPT Code: 82248

Specimen Type: Blood

Tube Type/Collection Container: Green top ( lithium heparin ) tube or Red top ( no anticoagulant )

Collection Volume: 0.6 mL (minimum 0.4 mL)

Cause for rejection: Hemolysis, lipemia, specimen exposed to light

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Diazo Method

Special Instructions: Protect the specimen from light exposure. Ask that the blue bilirubin lights in the NICU be turned off while collecting.

TAT: 1 hour

Panel Includes: Total and Direct Bilirubin


Lab/Phone: 330-746-9623

Additional Info: Reference range is age dependent; available on patient report

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: