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. ANAlyzer   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for ANAlyzer
CPT Code: 86038, 86160x2, 86225, 86235x5, 86376, 86431, 83520

Specimen Type: Blood

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

Collection Volume: 10.0 mL (minimum 5.0 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Immunochemiluminometric Assay (ICMA), Indirect Fluorescent Antibody/Image Analysis (IFA/Image), Farr Radiobinding Assay, Turbidimetry (TURB), Enzyme Immunoassay/Line Immunoblot Array (EIA/LIA), Indirect Fluorescent Antibody (IFA)

Special Instructions: -

TAT: 3-6 days

Panel Includes: ANA, dsDNA Autoabs, U1 RNP/snRNP IgG Autoabs, Smith IgG Autoabs, SS-A IgG Autoabs, SS-B IgG Autoabs, Scl-70 IgG Autoabs, Thyroid Peroxidase Autoabs, C3 Complement, C4 Complement, Rheumatoid Factor, Ribosomal P Protein Autoabs


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: