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. Lymphocyte Mitogen Screen   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Lymphocyte Mitogen Screen
CPT Code: 86353

Specimen Type: Blood

Tube Type/Collection Container: Green top (sodium heparin) tube: Whole Blood

Collection Volume: 20.0 mL

Cause for rejection: -

Storage: Ambient

Availability: Sent to reference lab

Methodology: Radioactive thymidine uptake in cell culture

Special Instructions: Deliver specimens to the lab within 24 hours of collection. Specimen must be received by 3:00 PM Monday -Thursday. Do not draw Friday-Sunday. Draw an additional 8.0 mL whole blood in a green top tube for request of 3 or more drugs/antigens.

TAT: 9 days

Panel Includes: LTT Antigen, Ratio, Control, Phytohemagglutinin, Comment


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: