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. Thrombin Platelet Aggregation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Thrombin Platelet Aggregation
CPT Code: 85576

Specimen Type: Blood

Tube Type/Collection Container: Specially prepared sodium citrate tubes

Collection Volume: 10.0 mL

Cause for rejection: Specimen hemolyzed, clotted, or grossly lipemic; specimen from patients who have taken drugs that inhibit platelet function. test not scheduled in advance.

Storage: Ambient

Availability: Test scheduled for weekday mornings only

Methodology: Standard Optical Aggregation in PRP (Platelet Rich Plasma)

Special Instructions: NOTE: Call CCL in advance to schedule test. Test can be scheduled for weekday mornings only. Hematology staff must be at bedside to collect. Special handling is required.

TAT: 72 hours


Lab/Phone: 330-543-8416

Additional Info: Reference range: Normal Study

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: