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. Transglutaminase IgA   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Transglutaminase IgA
CPT Code: 83516

Specimen Type: Blood

Tube Type/Collection Container: Red Top (no anticoagulant) tube

Collection Volume: 3.0 mL (minimum 1.0 mL)

Cause for rejection: Excessively hemolyzed, lipemic, or grossly contaminated specimen; drawn in incorrect tube; QNS

Storage: Refrigerated

Availability: Mon, Wed, Fri (0800-1700)

Methodology: Enzyme Immunoassay (EIA)

Special Instructions: -

TAT: 24-72 hrs

Panel Includes: -


Lab/Phone: 330-543-8576

Additional Info: Reference Range: < 20 Negative; 20-30 Weak Positive; >30 Moderate to Strong Positive

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: