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. IgG Synthesis and Index   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for IgG Synthesis and Index
CPT Code: 82040

Specimen Type: Blood & CSF

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

Collection Volume: 3.0 mL (minimum 1.5 mL) serum and 3.0 mL CSF (minimum 1.5 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Fixed Rate Time Nephelometry

Special Instructions: The collection date and time must be the same for both specimens. Both serum and CSF must be sent for calculation of synthesis rate by nephelometry. CSF must be crystalline clear.

TAT: 24 hours


Lab/Phone: 330-543-8418

Additional Info: Reference ranges are 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: