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. Plasminogen Activator Inhibitor   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Plasminogen Activator Inhibitor
CPT Code: 83520

Specimen Type: Blood

Tube Type/Collection Container: Blue top (sodium citrate) tube

Collection Volume: 2.5 mL (minimum 1.0 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Enzyme-Linked Immunosorbent Assay (ELISA)

Special Instructions: 3.2% sodium citrate is the preferred anticoagulant. 1. Spin down, remove plasta and spin plasma again Freeze specimen immediately at < or = -40C, if possible Note: Double centrifuged specimen is critical for accurate results as platelet contamination may cause spurious results.

TAT: 7-12 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 3-72 ng/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: