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. Rubella IgM Ab   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Rubella IgM Ab
CPT Code: 86762

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 2.5 mL (minimum 1.5 mL)

Cause for rejection: Contaminated, heat-inactivated, or grossly hemolyzed specimens are unacceptable.

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Semi- Quantitative Chemiluminescence Immunoassay (CLIA)

Special Instructions: Allow specimen to clot completely at room temperature. Remove serum from cells ASAP. Parallel testing is preferred and convalescent specimens MUST be received within 30 days from receipt of the acute specimens; please mark specimens as "acute" or "convalescent".

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: < or = 19.9 AU/ml: Not Detected 20.0-24.9 AU/mL: Indeterminate > or = 25.0 AU/mL: Detected

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: