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. HLA-B27   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for HLA-B27
CPT Code: 86812

Specimen Type: Blood

Tube Type/Collection Container: Lavender top (EDTA) tube: Whole Blood

Collection Volume: 4.0 mL

Cause for rejection: -

Storage: Ambient

Availability: Sent to reference lab

Methodology: Flow Cytometry, Lymphocyte Microtoxicity

Special Instructions: Draw Monday-Saturday only. Deliver specimen to reference lab the same day specimen is obtained. Must be received in the Central Core Lab by 4:00 PM for proper delivery to reference lab. Days Performed: Mon-Sat

TAT: 2-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative

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: