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. Kleihauer Betke Stain   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Kleihauer Betke Stain
CPT Code: 85460

Specimen Type: Blood and 2 fresh smears

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood

Collection Volume: 2.0 mL (minimum 0.5 mL)

Cause for rejection: Specimen clotted or grossly hemolyzed; inadequate specimen

Storage: Refrigerated

Availability: Daily (0700-1200)

Methodology: Acid Elution (Modified Kleihauer-Betke Stain)

Special Instructions: Specimens arriving after 1200 will be processed the next day.

TAT: 24 hours


Lab/Phone: 330-543-8416

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: