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. Bone Marrow   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Bone Marrow
CPT Code: -

Specimen Type: Bone Marrow Aspirate and/or Biopsy

Tube Type/Collection Container: Specimen container

Collection Volume: 0.5 mL

Cause for rejection: Dry Tap"; clotted specimen"

Storage: Ambient

Availability: Mon-Fri (0800-1530); Sat-Sun (1000-1400)

Methodology: Microscopic evaluation of Wright's stained coverslip preparation

Special Instructions: Physician must schedule procedure with CCL (x38416), indicating any cultures, biopsy, chromosome studies, immunological tests or other special orders. Nursing station must call CCL when the physician arrives to perform the procedure.

TAT: 48-72 hours


Lab/Phone: 330-543-8416

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: