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. Lactic Acid   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Lactic Acid
CPT Code: 83605

Specimen Type: Blood

Tube Type/Collection Container: Gray top (fluoride/heparin) tube

Collection Volume: 2.0 mL

Cause for rejection: Specimen not received on ice, specimen not delivered to lab within 2 hours of collection.

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Enzymatic, colorimetric method

Special Instructions: Patient should not exercise 30 minutes prior to collection. Try to collect sample without using a tourniquet. If this is not possible, apply a tourniquet for no longer than 3 minutes. Do not instruct patient to clench and unclench fist to pump" the vein. Place specimen on ice and deliver to lab immediately."

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Reference range: 0.5-2.2 mmol/L

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: