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 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: