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. Hemoglobin, Plasma   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hemoglobin, Plasma
CPT Code: 83051

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium heparin) tube

Collection Volume: 0.7 mL (minimum 0.7 mL)

Cause for rejection: -

Storage: Frozen

Availability: Daily (0800-1600)

Methodology: Spectrophotometry

Special Instructions: Available on ECMO patients only. Any other requests must have a pathologists approval.

TAT: 1 day


Lab/Phone: 330-543-8484

Additional Info: Reference range: Normal = < 5 mg/dL; Critical = > 50 mg/dL

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: