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. Anti-DNase B Titer   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Anti-DNase B Titer
CPT Code: 86215

Specimen Type: Blood

Tube Type/Collection Container: Red Top (no anticoagulant) tube

Collection Volume: 2.5 mL (minimum 1.5 mL)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Nephelometry

Special Instructions: 1-3 days

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference Values: <5 years: < or = 250 U/mL 5-17 years: < or = 375 U/mL > or = 18 years: < or = 300 U/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: