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. PG Amniostat   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for PG Amniostat
CPT Code: 84081

Specimen Type: Amniotic Fluid

Tube Type/Collection Container: Fluid Container

Collection Volume: 10.0 mL (minimum 4.0 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Agglutination

Special Instructions: Protect from light. Call the Summa Tox Lab 330-375-3639 to let them know a specimen is being sent.

TAT: 2 Hours


Lab/Phone: 330-543-8418

Additional Info: Reference range: Absent

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: