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. TSH   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for TSH
CPT Code: 84443

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 1.2 mL (minimum 1.2 mL)

Cause for rejection: Hemolysis

Storage: Frozen

Availability: Mon-Fri (0800-1600)

Methodology: Chemiluminescent Assay

Special Instructions: Do not use serum separator tube. Specimen must be in lab by 1300 for same day results. Specimen from a newborn should be drawn 2-3 days after birth.

TAT: 1 hour


Lab/Phone: 330-543-8484

Additional Info: Reference range: 0.35-5.50 ulU/mL

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: