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: Gold top (SST) tube

Collection Volume: 5.0 mL (minimum 3.0 mL)

Cause for rejection: Hemolysis

Storage: Frozen

Availability: Sent to reference lab.

Methodology: High Performance Liquid Chromatography

Special Instructions: Protect from light. Submit specimen in amber transport tube. Obtain specimen following an overnight (12 hour) fast. Patient should not consume alcohol for one day prior to blood draw. Days Performed: Sun, Tues-Sat

TAT: 3-8 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 0.10-2.20 ng/mL

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: