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. Urine Lead 24 HR   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Urine Lead 24 HR
CPT Code: 83655

Specimen Type: Urine Container

Tube Type/Collection Container: 24 Hour Urine Collection

Collection Volume: 10 mL (minimum 5 mL)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Inductively Coupled Plasma/Mass Spectrometry

Special Instructions: 10.0 mL (minimum 5.0 mL) aliquot from a well-mixed 24 hour urine. Collect specimen in clean container. Instruct patient on 24 hour urine collection. To begin the urine collection, have the patient void. DISCARD THIS URINE SPECIMEN. This is best done with the first morning specimen. Note the time and record on the requisition. From then on collect all the urine that is voided and place in contianer. If more than one container is needed, please mark the first as #1 of 2 and retain on the floor until collection is complete. The final void should be made 24 hours after the first void described earlier. The specimen should be included with collection. Refrigerate urine during collection. Indicate total volume on requisition. Send aliquot in metal-free plastic container. Specimen must not come in contact with rubber, metal, or glass. Urines should not be collected within 48 hours after administration of gadolinium (Gd) contianing contrast medial ( may occur with MRI studies).

TAT: 2-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Lead, Urine ug/L: 0-23 Lead, Urine ug/day: 0-31 Days Performed: Mon-Sat

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: