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. Platelet Count   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Platelet Count
CPT Code: 85049

Specimen Type: Blood

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

Collection Volume: 0.3 mL and 2 fresh smears

Cause for rejection: Specimen hemolyzed, clotted, diluted with IV fluid; drawn with heparin or contaminated with heparin;improperly prepared blood smears

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Unopette with Phase Microscopy

Special Instructions: Indicate clearly if a specimen has been drawn from an arterial line or from a line that has been rinsed with heparin.

TAT: 4 hours


Lab/Phone: 330-746-9623

Additional Info: Reference range is available on patient report

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: