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. Liver - Kidney Microsome (Mayo)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Liver - Kidney Microsome (Mayo)
CPT Code: 86376

Specimen Type: Blood

Tube Type/Collection Container: Red top tube

Collection Volume: 1.5mL (minimum 1.2mL)

Cause for rejection: Severe hemolysis, severe lipemia

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Enzyme-Linked Immunosorbent Assay (ELISA)

Special Instructions: Draw blood in a plain red top tube or serum gel tube. Spin down and send 0.5mL serum refrigerated. Submitting the minimum specimen volume makes it impossible to repeat or to do confirmatory testing or perform reflux testing. In some situations a minimum specimen volume may result in QNS.

TAT: 5 days


Lab/Phone: 330-543-8418

Additional Info: See patient report for reference ranges Days Performed: Mon, Wed, Fri

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: