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. Porphobilinogen, Quantitative Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Porphobilinogen, Quantitative Urine
CPT Code: 84110

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 24 hour urine or random collection

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab. Days Performed: Wed-Mon

Methodology: Ion Exchange Chromatography/Spectrometry (IECS)

Special Instructions: 10.0 mL urine (minimum 5.0 mL) aliquot from well-mixed 24 hour or random urine in a clean container without preservative. Instruct patient on 24 hour urine collection. To begin the urine collection, have the patient void. DISCARD THIS URINE SPECIMEN. This is best done with the first morning specimen. Note the time and record on the requisition. From then on collect all the urine that is voided and place in container. If more than one container is needed, please mark the first as #1 of 2 and retain on the floor until the collection is complete. The final void should be made 24 hours after the first void described earlier. The specimen should be included with the collection. Refrigerate during collection. Protect from light.

TAT: 2-6 days


Lab/Phone: 330-543-8418

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 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: