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. Osmotic Fragility, RBC   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Osmotic Fragility, RBC
CPT Code: 85557

Specimen Type: Whole blood

Tube Type/Collection Container: Purple top (EDTA)

Collection Volume: patient 4.0 mL (minimum 2.0 mL) Normal control: 4.0 mL (minimum 2.0 mL)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Osmotic Lysis

Special Instructions: Immediately place specimen on ice after draw. Draw a control specimen at the same time from a normal, unrelated, non-smoking individual. Clearly write "normal control" on label and indicate sex of control on same label.

TAT: 2-5 days


Lab/Phone: 330-543-8418

Additional Info: See patient report for Reference Values

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: