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. Vitamin K   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Vitamin K
CPT Code: 84597

Specimen Type: Blood

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

Collection Volume: 5.0 mL (minimum 2.0 mL)

Cause for rejection: Gross lipemia

Storage: Refrigerated

Availability: Sent to Mayo Medical Laboratories

Methodology: Liquid Chromatography-Tandem MAss Spectrometry (LC-MS/MS)

Special Instructions: Protect from light. Submit specimen in amber transport tube. Obtain specimen following an overnight (12 hour) fast. Days Performed: Mon-Fri

TAT: 2-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: > 18 years 0.10-2.20 ng/mL <18 years: not established

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: